| Employee's First Name: |
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| Employee's Last Name: |
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| Employee's Annual Salary Rate: |
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| Years of Continuous State Service Completed: |
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| ( As of layoff or retirement
date, the calculator rounds up service. Please enter a whole number. ) |
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| Last Leave Anniversary:
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| Is Employee in VSDP?
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| Is Employee Vested in VRS?
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| Is Employee Full-time? (F or Q
status) |
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| Is Employee 50 Years Old or
Older?
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| Employee's Health Benefits Plan: |
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Type of Health Benefits Coverage:
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