IU 18/20 RETIREMENT PLAN
GAINFUL EMPLOYMENT CERTIFICATION
Period July 1, 2011 through December 31, 2011

RECORD REPORTABLE EARNINGS:

On the previous page you indicated that you had reportable earnings from Indiana University, an entity funded by the State of Indiana, or a not-for-profit organization that would appear to receive intermediary payments from Indiana University or the State of Indiana. Please record your earnings here, then complete and submit the rest of this form:

EMPLOYEE INFORMATION:

Name: *Last   *First   M.I.

 *Email:

CERTIFICATION AND SIGNATURE:

I certify that to the best of my knowledge the above information is true and correct. I understand that falsification of information will result in the termination of my IU 18/20 Retirement Plan benefits. I understand, if requested by Indiana University, I must provide documentation of my reported earnings for all periods of time during which I received IU 18/20 Retirement Plan benefits and if this request is not fulfilled in a timely manner it will result in the termination of my IU 18/20 Retirement Plan benefits.

Typing my name in the space provided constitutes an electronic signature and certifies that the information supplied on this form is true and correct.

*Employee signature:

Date:

If you had no reportable earnings please return to and complete the previous page of this form.