Utah Retirement Systems (URS) Post-Employment Form

Spanish Fork City is a Utah Retirement Systems (URS) participating agency. As a participating agency, post-retirement employment/vendor/contractor rules apply. Post-retirement means returning to work either on our payroll or as a vendor/contractor for a URS participating employer following your retirement date with the Utah Retirement Systems. Different standards apply depending on whether you return to work within one year or after one year from your retirement date with URS.

You must separate from employment (including part-time and vendor/contractor arrangements) with any participating employer for one year following your retirement date with URS, unless eligible exclusions apply.

You are responsible for understanding post-retirement employment rules and ensuring there is no violation of such rules by providing services to Spanish Fork City. If you have any questions, call the URS office at 801-366-7770 or 800-695-4877 before you begin any work for or provide any services to Spanish Fork City.

Business Name *

If Sole Proprietor and don't have a business name; enter your name

Are you a Sole Proprietor?*

YesNo

Sole Proprietor Birth Date*

Are any of your Officers or Principals Utah Retirement System (URS) Retirees*

YES, ONE OR MORE OF OUR OFFICERS AND/OR PRINCIPALS IS A URS RETIREE Contractor certifies that following contractor(s), officer(s), or principal(s) of the business ARE Utah Retirement Systems (URS) retiree(s). Contractor further certifies that the URS office has been properly notified of post-retirement reemployment of such individuals. Contractor assumes all responsibility for compliance with post-retirement reemployment restrictions, notifications,and/or penalties that may occur at any time in the future if found to be in violation. URS Retirees:No

Are you a Utah Retirement Systems Retiree (URS)*

NO, I AM NOT A URS RETIREE Contractor (a sole proprietor) certifies that he or she is NOT a Utah Retirement Systems (URS) retiree and acknowledges that should he/she retire from the URS system in the future, he/she assumes all responsibility for compliance with post-retirement reemployment restrictions, notifications, and/or penalties that may occur at any time in the future.YES, I AM A URS RETIREE Contractor certifies that they are a Utah Retirement Systems (URS) retiree. Contractor further certifies that the URS office has been properly notified of post-retirement reemployment of this individual. Contractor assumes all responsibility for compliance with post-retirement reemployment restrictions, notifications,and/or penalties that may occur at any time in the future if found to be in violation. URS Retirees:

URS Retiree Name*

First NameLast Name

URS Retiree Social Security Number*

If you have additional URS Retiree's Please Enter their names and Social Security Numbers in the box below

State law requires that the City, through Human Resources, provide such information to URS.

As a condition of doing business Spanish Fork City, you hereby accept responsibility and waive all claims of joint liability against Spanish Fork City for any violations of the URS post-retirement re-employment/vendor/contractor rules.

Contractor Signature*

Date*

Date

UTAH RETIREMENT SYSTEMS POST-EMPLOYMENT RESTRICTIONS ACT CERTIFICATION & RELEASE