Exit Check Out Sheet

Exit Check Out Sheet

Employee Name: _______________________________________

Employee Number: ______________________________________

I request the following:

Other: _____________________________________________________________

Service Record:

_____________________________________________________________

_____________________________________________________________

If copies are to be sent to a school district, state mailing address below:

District: ________________________________________________________________________________________________________________

Mailing Address: _______________________________________________________________________________________________________

Number or P.O. Box

Street

City

State

ZipCode

I wish to withdraw my Teacher’s Retirement Funds:

Yes

No

If I’m resigning at the end of the school year, I understand that all insurance coverage, both district and employee paid, will

terminate with the district by midnight on the last day of the school district’s benefit plan year.

If I’m resigning during the school year I understand that all insurance coverage, both district paid and employee paid, will

terminate with the district by midnight on the last day of the month in which I resign.

I am aware that any direct deposit or credit union deductions will cease at the time I exit employment with the district. Any

final monies due me will be provided in my payroll check.

Date: ___________________________________________________

Initials: ___________________________

Mailing Address or forwarding address for W-2: __________________________________________________________________________

__________________________________________________________________________

___________________________________________________________

________________________________________________________

Employee Signature

Human Resource Representative

________________________________________________________

Date

Socorro Independent School District does not discriminate on the basis of race, color, national origin, sex, age, or disability in its employment practices or in providing education services, activities, and programs, including career

and technical education (vocational programs). For additional information regarding Socorro Independent School District’s policy of nondiscrimination contact: Human Rresources Officer (915) 937.0201,

12440 Rojas, El Paso, TX 79928