Intent to Retire

Employee's Legal Name

Job Title

Retirement Date

Must always be the first day of the month. If the exact date is unknown, please enter a tentative date.

Date of Hire

Date of Birth

Age

Mailing Address / Street Address

City

State

Zip Code

Phone Number

Please provide personal phone number (not UWG office number)

Email Address

Please use personal email -- Not UWG Email address

Do you have any prior State of Georgia service?

To include other USG institutions

Employee Type

Exempt/Non-Exempt

Retirement Provider

Supplemental Retirement Plan

This would be your 403b or 457b

Supplemental Retirement Vendor

Notes

*

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