Classified Resignation/retirement Form
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2LOS ANGELES UNIFIED SCHOOL DISTRICT
PERSONNEL COMMISSION
CLASSIFIED RESIGNATION/RETIREMENT FORM
I hereby resign from employment with the Los Angeles Unified School District effective at the end of the wor
k
day
/
/
Name:
Employee No.:
Last
First
MI
Social
Security No.:
-
-
Date of Birth:
/
/
Home Telephone
Home Address:
No. & Street
City
State
Zip Code
Name of
Work Location:
Job Title:
Reason for resigning:
I am retiring, effective
/
/
From:
CalPERS
STRS
(If you plan to continue working as a retired substitute, please contact the Classified Employment Services.)
You may withdraw your resignation or retirement within 48 hours after it is submitted.
I have no other LAUSD employment
I am resigning to accept a certificated assignment with LAUSD
(Employees have only 60 days from date of hire to make a retirement system election. Please complete Form ES 372.)
Name of new work location:
I understand that if I am resigning during a disciplinary investigation or process, I will not be eligible for
re-employment with LAUSD.
Employee Signature:
Date:
/
/
If you are a member of the Public Employees’ Retirement System (PERS), please see the attached for additional information.
If you are a member of the State Teacher’s Retirement System (STRS), please contact STRS directly at (800) 228-5453.
If you are a member of the Public Agency Retirement System (PARS), please contact PARS directly at (800) 731-7884.
ADMINISTRATIVE ACKNOWLEDGEMENT:
Site Administrator’s Signature
Title:
Date:
/
/
DISTRIBUTION:
Employee is to keep a copy. Please send the original to the Classified Employment Services, P.O. Box 513307,
th
Los Angeles, CA 90051-1307 or via school mail to the Classified Employment Services, Beaudry Building, 12
Floor.
*PC5209*
PC Form 5209 Classified Resignation Form, Revised 08/2014
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