Separation Notice (Form SN)

Member Information

Last Name First Name Date of Birth Address City Province Postal Code

Employee Information

Last Job Position

Employment Status Full-time Part-time, Seasonal or Casual

Last Salary or Pay Rate Hourly Annually

Annual Full Time Base Hours for the Position 2080 1950 1820 Other - please specify:

1st Pay Period Start Date for Year of Separation (yyyy-mm-dd)

Separation Information

Date of Separation (YYYY-MM-DD)

Note: Enter the official end of employment date. Include any period covered by vacation pay paid as salary continuance or pay in lieu of notice. For employees not returning from disability, layoff, or leave, use the resignation date, termination date, or the date disability payments ended.

Was this member on layoff, leave of absence or disability immediately prior to Separation Date? Yes No

Last Pensionable Earnings Paid Until (yyyy-mm-dd) (YYYY-MM-DD)

Type Of Separation Termination(under age 55) Retirement (age 55 or over) Death (please provide the following details)

Executor Contact Information Name of Executor or Next of Kin Phone Number Mailing Address

Basic Life Insurance & Disability Income Plan

Did this employee contribute to Basic Life Insurance to the Date of Separation? Yes No Not Applicable

Did this employee contribute to the Disability Income Plan? Yes No Not Applicable

Was this member in receipt of WCB or Disability Benefits in the separation year? Yes No

If this member was a Full-time, were there any unpaid LOA in the separation year? Yes No

If yes, how many hours?

Pension Information

Pensionable Hours for Current Year	Pensionable Earnings for Current Year's Service	Pension Contributions for Current Year's Service

Service Year for Retro Pay	Retro Pensionable Earnings for Prior Year's Service	Pension Contributions for Prior Year's Service Retro Pay
	$	$
	$	$
	$	$
	$	$
	Total Pensionable Earnings Paid in Year of Separation	Total Employee Contributions Remitted in Year of Separation
	$	$

Vacation Pay Paid as regular earnings or a continuation of pay, vacation hours and earnings are pensionable and included in the above. Paid as a percentage of pay, vacation pay is pensionable with no pension hours. Vacation pay is included in the above. Paid as a lump sum payout on termination. These are NOT pensionable and are not included in the above.

Employer Information

Employer Number Employer Name Name of Contact Person Email Phone Date (yyyy-mm-dd)