Request for Retirement Certificate

Part A Requestor's Information

Requestor's Name:

Requestor's Telephone:

Requestor's E-Mail Address:

Requestor's Campus Address

Requestor's UDDS:

Requestor's Department Name:

Certificate Distribution:

Pick Up Send

Part B Retiree Information

Name as it will appear on the certificate:

Last Name:
First Name:
Middle Int:

Classification:
Classified Unclassified
Gender:
Male Female

Retirement Date: (mo/day/yr)

Years of UW Service:

Combined Years of State and UW Service:

Date Certificate Required:
(mo/day/yr)

Please allow 14 days to process your request. If you are picking up the certificate, you will be notified by email when it is ready. Certificates may now be picked up at 21 N Park Street, Suite 5101.