Download a printable version: Statement of Earnings rtf format of statement_of_earnings.rtf
[.rtf] format




A person who has been retired and who is receiving a pension, disability pension or retirement allowance from the commonwealth, or from any county, city, town, district or authority may be employed in the service of the Commonwealth for up to 960 hours in the aggregate in any calendar year. Such person shall serve at the will of the Appointing Authority.

I am / am not (circle) receiving a pension or retirement allowance from the Commonwealth of Massachusetts; or from any county, city, town, district or authority.

Retirement Information:

Retired From: ____________________________

Position Held: _____________________________

Retirement Date: ___________________ Salary: _________________

Pension: _____________________

960-Hour Position Information:

Position Applied: _______________________________________

Hourly Rate: _____________ Hours Per Week: ______________

Maximum Annual Earnings: ____________ (attach explanation of computation)

Weekly Schedule: ________________________________________

I understand that I am required to certify to my employer the number of days or hours that I have been employed in any calendar year and the amount of earnings during that calendar year. If the number of hours exceeds nine hundred and sixty, or if the earnings exceed the amount allowable under M.G. L. Chapter 32 Sec. 91 (b), I am required to return to the appropriate treasurer or other person responsible for the payment of compensation all such earnings as are in excess of said allowable amount.

___________________________ _____________________________

Print Employee Name Signature of Employee/Date

____________________________ _____________________________

Supervisor Approval/Date HR Approval/Date