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C 1 T Y:x C) F <br />ftN J[ KES <br />CITY OF LINO LAKES EARLY <br />RETIREMENT INCENTIVE <br />PROGRAM APPLICATION <br />Name: Position Title: <br />Department: Date of Application: <br />❑ I voluntarily elect to apply for the City of Lino Lakes sponsored early retirement incentive program. I <br />understand that, if approved, the City will: <br />1. Contribute an incentive equivalent to twelve (12) weeks of gross salary at my current rate of pay. <br />This payment will be taxable and paid directly to me; and <br />2. Deposit ten thousand ($10,000.00) dollars into a Post Employment Health Care Savings <br />Account. I will be offered benefits continuation at the point of separation and it will be my <br />responsibility to pay any continued benefits in a timely manner. <br />In return, I understand and agree that I will: (1) submit my voluntary resignation in writing with a <br />resignation date that corresponds to the date listed below, and (2) sign the Waiver and Release of Claims <br />form waiving my rights to pursue any legal claim against the City of Lino Lakes, its employees and <br />officers. <br />I agree that if my application for an early retirement is approved by the Director of Administration, I will <br />resign from my employment with the City of Lino Lakes on or before 16 October 2009. <br />❑ I understand that any vacation or sick leave severance payments will be distributed according to my <br />labor agreement or, if I am not a member of a bargaining unit, the City's personnel policy and <br />applicable post - employment health care savings contribution requirements. <br />❑ I have read and understand all the information in the Early Retirement Incentive Program. I <br />understand that once my application is accepted by the City of Lino Lakes, my application cannot be <br />revoked or nullified by me. I further understand that the Director of Administration retains the sole <br />discretion to approve or deny any applications based on the number of applications received, the <br />potential cost savings or lack thereof, an employee's critical skills, or the business needs of the City. <br />Employee Signature Date <br />Status of Application: <br />❑ Approved <br />❑ Denied <br />• Dan Tesch, Director of Administration Date <br />