Gainful Employment Certification | UHRS

IU 18/20 RETIREMENT PLAN
GAINFUL EMPLOYMENT CERTIFICATION
Period July 1, 2012 through December 31, 2012

REPORTABLE EARNINGS:

In accordance with University policy, IU 18/20 Retirement Plan (Plan) recipients cannot receive Plan benefits while receiving compensation from Indiana University or any other entity funded by the State of Indiana.

	I had NO reportable earnings from Indiana University, any entity funded by the State of Indiana, or any not-for-profit organization that would appear to receive intermediary payments from Indiana University or the State of Indiana. Please click button then complete and submit this* page.*
	I had reportable earnings from Indiana University, an entity funded by the State of Indiana, or a not-for-profit organization that would appear to receive intermediary payments from Indiana University or the State of Indiana. Please click button then complete and submit the next* page.*

Complete the information below if you had NO reportable earnings (* = required field)

EMPLOYEE INFORMATION:

Name: *Last *First M.I.

*Email:

CERTIFICATION AND SIGNATURE:

I certify that to the best of my knowledge the above information is true and correct. I understand that falsification of information will result in the termination of my IU 18/20 Retirement Plan benefits. I understand, if requested by Indiana University, I must provide documentation of my reported earnings for all periods of time during which I received IU 18/20 Retirement Plan benefits and if this request is not fulfilled in a timely manner it will result in the termination of my IU 18/20 Retirement Plan benefits.

Typing my name in the space provided constitutes an electronic signature and certifies that the information supplied on this form is true and correct.

*Employee signature:

Date:

University Human Resource Services
December 2012