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Kentucky Retirement Systems Perimeter Park West l1260 Louisville Rd. l Frankfort KY 40601-6124 Phone 502 696-8800 l Fax 502 696-8822 l kyret. ky. gov Print Form Form 6751 Revised 01/2010 Member and Employer Certification Regarding Reemployment IMPORTANT NOTICE This form will not be accepted unless it is fully completed by both the employer and employee. Kentucky Retirement Systems Perimeter Park West l1260 Louisville Rd. l Frankfort KY 40601-6124 Phone 502 696-8800 l Fax 502 696-8822 l kyret. ky. gov Print Form Form 6751 Revised 01/2010 Member and Employer Certification Regarding Reemployment IMPORTANT NOTICE This form will not be accepted unless it is fully completed by both the employer and employee. Member Information Please provide your Member ID or Social Security number in the Member ID box below. Member Name Member ID Reemploying Agency Member Certification Subject to the penalty of perjury I certify that 1. I am receiving or have applied to receive a retirement benefit from one of the retirement plans administered by the 2. Check one of the following I DID NOT have a prearranged agreement prior to retirement to return to work in any capacity after retirement with an employer participating in the Kentucky Retirement Systems. I DID have a prearranged agreement prior to retirement to return to work in some capacity after retirement with an employer participating in the Kentucky Retirement Systems. 3. If I did have a prearranged agreement prior to retirement to return to work after retirement with an employer participating in the Kentucky Retirement Systems I have fully disclosed in writing to Kentucky Retirement Systems the details of that agreement. I understand that any prearranged agreement could result in the voiding of my retirement benefit and I could incur significant tax penalties. 4. Are you Medicare eligible Yes No 5. I understand that I have a duty now and in the future to disclose in writing to Kentucky Retirement Systems my employment in any capacity with an employer participating in the Kentucky Retirement Systems. accepted employment under a personal services contract including as an independent contractor with an employer employment means that I will perform work for an employer participating in the Kentucky Retirement Systems. I further acknowledge that I have full understanding that any person who provides a false statement report or representation is subject to the penalty of perjury in accordance with KRS 523. 010 et seq. Signature Date Employer Certification To be completed by an employer participating in the Kentucky Retirement Systems. 1. My name is. I am the agency head appointing authority or authorized designee of the employer participating in Kentucky Retirement Systems which will be the employer of the above-named member. I have made personal inquiry and confirmed that my agency DID NOT have a prearranged agreement prior to Title. ky. gov Print Form Form 6751 Revised 01/2010 Member and Employer Certification Regarding Reemployment IMPORTANT NOTICE This form will not be accepted unless it is fully completed by both the employer and employee. Member Information Please provide your Member ID or Social Security number in the Member ID box below.

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