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01-31-1994J('I: •:a?'d„?r-a.?t?;.?? sit";,fir` -?t;?.?,9?:1. •t- '.r;: a - ., .. ? 'R s t ',>,i. jgS,,,.t,.- ;,,? 'ifs.' ?'i-. ?:4t? ,??, ,?•' ?j ., ?,'• , ?f.?. .. .? ? '}<d.'?? zi• ,?r'I, ,r`f rlS;. f f.,;; 1:' 'i i. ? S' 1d,' ?1? ' ? 'ii? •fj 'p`' i? :dif N:/',yS`?•!',' .. r .;?.?Ri,. 's... ? ? ? -r ?' •.id`' -Y-•i.`. ,i, •?'':f, /%:? i?df;' i? u1 ? ,. ? . ti,' s•?r`. ??;?'r ..?{"t?'?•'`,. y•s• i' '!r .i'<=., c.Dfts.%•j"? 4u,>i 't'°' -v,iiy?}t-i't..^rS, {r,`,,y:?...r: ;i'?:,.r,:;: ':'`•- 'i `•"iR" x,• ` .i '5:'i tit„ .•in -• • . ` ?. -?s ? . a rY F:.?, G3s ? , . ?,. ./ .e!i: • ?' ' 4xdl?4?{s?'??frtxtF .r?: ? 4r:ra ,erg: ,. k.. ? ?dS', I-` •F f;i::',4s ?- mt.c. •r,?. t::. t . €'' •,` '? ; i• r'. . }'t ?',::. Irv ell erasion -1 94? k '• . ' ? ' ' • • ' • ? ;l ? : I _, _ f. ;s a `_I. : c`, 1.;7' ? ? .t ? ? . ,. .i: r ?. }. t??'br .f 4?r, (1.'??'•"M '4 4 :, E ?'. ,.."i,.a. ?t+,a, •.S ?s y2' k i ?.f!?r°`" i"J .?:•S?:"?'t"? ?'?:??J?. L:?-- •1, ''t•tj•'"' ..... s .?.+•s?+,rhtpi?. ?t"S ???rfdz-.. .Rt ?.:'ra,t . . +.<. .. .. r > lei ? ,, ?tiiJ , • .?,: .. .. •r?` ? ... ?, ACTION AGENDA Board of Trustees of the Employee s' Pension Fund, ' ' January 31, 1.994 9:OO A.M. . t.'. 1 Cail to order 9:00 a.m. Approval, of Minutes ". 2. Approved as submitted. I. ; of 1/18/94 3.. Request for acceptance 3. Approved. into membership: ' r .. a) David R.. Brady f b) Carlos Lang. .. . C) Jacqueline R. Maltry. ° d) Lucette'M. Wombacher , 4.. Regular Pension to be granted. 4. Granted: John C,, Brady Regular Pension to be granted: 5. Granted. Donald A. Konen, Jr, ' 6.. Job-Connected bisability. Pension 6. Granted. '. to be granted:' Earl J. Stanford 7.- Other Business: 7. None. ' 8. Adjournment: 8. 904 a.m: l ? ls.: ,l',i'r r,1•. ?. ... F• ;t?,??)k??: ;?r:? :i'"e .,i. ?;; t' '' ?'s • ' .u. .;r?` ... :rift ,•e, ?r?, 'k ? ' e , !U : [' r ' 1. t?.fY, , . , a : ./•. s ?t;.? ',,' , i?. L'?r . • . ? j ? z ? ' ? ' P i ? : ,r t.j• ' •? k it ' ' . ; ?• ? ' e ?Jf .f ? ? i. , Ji ,r. .j ? ' ?+ ; ';! F ; `F•( 1sl ?• ? ?. ? f ' ? , `?r.?rrr, .£. . .. r . e ' ' ' ! I , P ai ?:i ?r'? . r • , .' '?t'''}`? .: i, .i! i _ Z ? ?t ' i4 ? ' • .. k ? .. ? f .. I ? • ' 1. '3- . `Y,-F'? ; «j .{ y ((.`,1t k, '1.. :? 1 F.: M[.. ?. , ? .. ?! 1' y' .. ? 1 P? i ' ? ' i%s? ?• ' ' '' ' ` ? « •4, ? . .t r , d-,.r. . .t k • ?{ ? .f r..(".Irr :? :.i?,f;'-'e:?11'::;: `:;:???tc•. 'ice r.> . • ? , ? ? .. `1 ',,, 1. g, o,j•.^,!.•'it ??i'??: "%i? ?i, `??? ?i ?t"'?ai:?: ? .•. ? i5 .t? 1 . 1.? ')i , • ' ,'? t,'hrykn '•?si L-iS•:.,' ?r p ] ?], F?eP' nd4' i9 .,Y.,4t'. t• `x iPd^` £.'fJ ..d'• d: >?' F:'? ?.1 • i : ?' • ' f f ? ' ? ° ?^i47 ?a ? ? ? • ' ' ?} t YY••T ' ? , .. (i, Y'`:°5 ,.17 ' ? ~? ,l1 .. : " .?' ... } :{t ' ??i •?i'Z ' , t .} , { .t tl . f. Jt t if. fi . •5,.?.1, ..f-r ? v.. •?. , . I• ?'1 'fAh?1.w] y?' r.1.,..Jy? .•. r.....-. .. ,. ?.; ? .?Q i, fS .y .' ? } . .. a ... ..e . r(_. .'.1?..-a .e,'r7 P .'T. 11. k .. . AGENDA ' +' Board of T ustees f the Ein e l ' nsio P F d . r o p oye s °. . e n un i January' 31, 1994 9:00 A.M. , C . ? ? .. ? ' I J,' •'. .. 1. Calf to order ' , ' ? ? ? ,? ? ? „f , ' I , ,. 2.: Approval of Minutes ;of 1/18194' 3. , ' Request for acceptance f . into membership: ' a) David R. Brady, ; b)' Carlos Lang c) Jacquelin6L R. Maltry' ' d) Lucette M. Wornbacher 4. Regular Pension to be granted: I:. . " John'C. Brady. i; 5: Regular Pension to be granted. Donald A. Konen, jr. B. :Job-Connected Disability Pension to be granted: Earl J. Stanford •7. Other. Business: . B., Adjournment: . t ' TRUSTEES OF THE EMPLOYEES' PENSION FUND Item # ' Agenda Cover Memorandum Meeting Date: 1 ?3? -94 Subject: Membership in Employees' Pension Plan Recommendation/Motion: Employee(s) listed below be accepted into the Employees' Pension Plan as recommended by the Pension Advisory Committee. ? and that the appropriate o"Icials be authorized to execute same. - - BACKGROUND: .-and-1!2b ss Qrpt./Div, David R. Brady, Gas Technician I Gas Carlos Lang, Police Recruit I Police Jacqueline R. Maltry, ? Senior Accountant DOAS/Finance Lucette M. Wombacher, Senior Accountant DOAS/Budget Seniority Date 12/ 13/93 7/ 1 3/92 12/27/93 12/27/93 Pension fcctive D, 12/13/93 1/8/94 12/27/93 12/27/93 Page Reviewed by: Originating Dept: Costs: Commission Action: Human Resources Total Legal NA ? Approved Budget NA ? Approved w/conditions Purchasing _t1© User Dept.: Current FY ? Denied Risk Mgmt. _NA ? Continued to: CIS Funding Source: ACM Advertised: ? Cnpt, Imp. Other NA Date: ? Operating _ Paper: ? Other Attachments: Not required Submitted by: Affected parties Appropriation Code: Letter(s) ? Notified ® Not required ? None Cit Manager L', .. ?tlri'.. 'h'i r.,_3 •.p i. r? • x. Y. y', .. ,xP: rklI, v'-ttb' ?,+;5: -6 Sk Fr,; 1y ?`,`:.' ',..; : [' ?'• . ' r •.c. .. :s ,L. •!.1 ^i.'l:f,?is i... .. , rs'1- i't. rr ?1 ?.: t.lr.t. .f'• .. .. .? , , i l .. :! .1. •.e , ..t. .l0 1: i .i 3'' ', t'. i . if .F CITY OF CLEARWATE, W ?: `• EMPLOYEES' PENSION, PLAN PENSION ADVISORY COMMITTEE TO: Pension Trustees FROM: Pension Advisory Committee SUBJECT: Recommendation for Acceptance into Pension Plan J^an.? ? 99 / , . , DATE: , As Trustees of the City of Clearwater Employees' Pension Fund, you are hereby notified that the employee(s) listed, below have been duly exnmined by a local' physician and each ins been designated ' as a "first class risk". These employees are eligible for pension membership as noted in the Pension. Eligibility Date ' column below, and it is the recommendation of the Pension Advisory Committ ee that they be accepted into membership. Pension Elig. 'v. Birth-:Date Hire Date p David R. Brady, Gns Technician 1, 2/19/37 .. l 2/ 1319 3 .12/13193 Gas Systen Carlos Lang, Police Recruit I, 8/7/71 7/13192 1/8/94* Police Department *Employee hired from permanent part-time to full-time permanent status. Hire date reflects date - hired as permanent part-lime. Jacqueline R: Maltry, Senior Accountant, DOASIFinance 6/25/51 12/27/93 12/27/93 Lucette M. Wombacher, Senior Accountnnt, DOAS/Budget 311 4/48 12/27/93 12/27193 • Item # Meeting Date: 1/31/94 Agenda Cover Memorandum Trustees of the Employees' Pension Fund Subject: Pension to be Granted. Recommendatlon/Motion: John C. Brady, Firefighter, Fire Department, be granted a regular pension under Section(s) 2.396 of the ' Employees' Pension Plan as recommended by the Pension Advisory Committee. ? and that the appropriate officials be authorized to execute same. BACKGROUND: John C. Brady', Firefighter, Fire Department, was employed by the City on December 17, 1973, and began participating in the Pension Plan on that date. His retirement will be effective on January 21, 1994, at the beginning of the day. Mr. Brady's pension was approved by the Pension Advisory Committee at its meeting of January 5, 1994. Based on an average salary of approximately $40,288 over the past five years and t h e formula for computing regular pensions, Mr. Brady's pension will approximate $20,144 annually. Charts from Finance which take into consideration mortality rates and age reflect the "present value cost of financing" this pension will be approximately $222,740. Page Reviewed by: Originating Dept: osts: U20.7.41? Commission Action: Human Resources Total Legal NA ? ? Approved Budget NA ? Approved w/conditions Purchasing --hLA User Dept.: Current FY ? Denied Risk Mg:nt.._IJA ? Continued to- cis IJA_ Funding Source: ACM r?-- Advertised: ? Capt. Imp. Other NA Date: ? Operating Paper: ? Other Pension Attachments: [Z Not required Submitted by: Affected parties Appropriation Code: Letter(s) ? Notified 0 Not required 646-07410-530100m585 ? None Citv Manaeer Human Resources Department 462.8870 'C'I, T Y U F C L E A R W'A T E R POST OFFICE BOX 4748 CLEARWATER, FLORIDA 34618.4748 TO: Honorable Mayor and Members of the City Commission as Trustees of the Employees' Pension Plan FROM: Pension Advisory Committee, COPIES: Debbie Bailey, Payroll Services Manager Employee's File SUBJECT: Regular Pension-John C. Brady DATE: January 5, 1994 The Pension, Advisory Committee received an application for regular pension from John C. Braidy on' January 5, 1994. Mr. Brady was employed by the City on December 17, 1973, and has been a participant in the Pension Plan since that date. The amount of Mr. Brady's pension will be computed by the Finance Department at such time as his last five years of service and salary can be calculated. By motion made and duly carried at its meeting of January 5, 1994, the Pension Advisory Committee approved/recommended a regular pension based on years of service for John C. Brady in accordance with Section 2.396 of the City Code. This pension will - be effective on January 21, 1994, at the beginning of the day. 1 hereby certify that the Pension Advisory Committee has approved the granting of a regular retirement pension for John C. Brady and the above dates arc' correct. i rman, bnsion Advisory Committee 4rb ''Equal Employment and Affirmative Action Employer'' i 1 . PENSION REQUEST FORM I. John" C. Brady " do hereby apply for retirement from the City of Clearwater General Employees' Pension Plan. "My benefits * date is December 17, 3.973 y (Entry date into pension plan) My'date of, hire'is December 17,. 1973 I. My birthday is December 12, 1952 .?_ My job classification is Firefighter and I work in the' Fire Department. Division. My resignation date is January 20, 1994, at the end of the day The type of pension for which I am applying is (check only one ): E _Regular Pension based on years of service Job-connected Disability Pension Non-job connected Disability Pension My spouse's name is: Gerry Lee Dependent children under the age of 18 and residing in my household are: William Patrick Sentember 1 1977 (Print Child's Full Name) (Child's Date of Birth) Joshua Duncan November 29, 1980 I hereby certify all of the above to be true and correct: (Signature) ;l Ja nuar 5 , 1994 (Date) "(Notary Public) )N0Tt,pY'i,11SLIC STATE Or F1CRIDA Vy CU* 9 ? f, UPW GEt .P.AL IM. WiD ND D F."', . CITY OF CLEARWATER GENERA EMPLOYEES' PENSION PLAN OPTIONS - FIREFIGHTERS OPTION fur 1: Employees can receive 'a lump sum payment for vacation and holiday pay and 112 of accrued sick leave at the time. of separation from the City. There will be no Sco . deduction for pension from this lump sum payment nor will this amunt count as earnings in the calculation of the pension. The lash day of work will be the termination date' and pension, benefits will begin the following dav. OPTION Employee can extend termination date by the time due (Only available to for vacation, holiday gay, and 112 of accrued sick leave. etnpio,vees hired Termination date will be the final day of extended time. prior to 10/1138) Pension benefits will begin the following day, ?axwxx.rx ry x+xsea aeva.x xx?rxx I. John C.' Brady an employee of the City of Clearwater; hereby apply for pension benefits under the General Employees' Pension Plan. I hereby certify that I fully understand the two options offered to me. I choose to retire using Option rc and wish my benefits to be calculated under this option. I understand that once this form is signed. my decision is irrevocable EINPL.OYEE'S SIGNAT _ t SOCIAL SECURITY 66-Q4-OOj7_ DDRESS' 4431 16th Street North 5t. Pet:ersburg, FL 337o3-4427 CW(ti r 'I?uI DATE: _ January 5, 1994 its TRUSTEES OF-THE EMPLOYEES` PENSION FUND Item # =r Agenda Cover Memorandum Meeting Date: 1/Q1194 Subject: Pension to be Grunted. Recommendation/Motion: Donald A. Konen, Jr., Tradesworker II, Building & Maintenance Division, General Services Department, , be granted a regular pension under Section(s) 2.396 of the Employees' Pension Plan as recommended by the Pension Advisory Committee, ? and that the appropriate officials be authorized to execute same. _-?!??nirrr?iwrr ^ - - __A - -__ ^ rw?r.w.•^?wrwrrwr?rrr.r?nwm urrr?arwrr?rrrr?>e ? BACKGROUND: Donald A. Konen, Jr., Tradesworker II, Building & Maintenance Division, General Services Department, was employed by the City on September 12, 1973, and began participating in the Pension Plan on March 13, 1974, His retirement will be effective on March 26, 1994, at the beginning of the day, Mr. Konen's pension was approved by the Pension Advisory Committee, at its meeting of January 5, 1994. Based on an average salary of approximately $31,320 over the past five years and the formula for computing regular pensions, Mr. Konen's pension will approximate $15,660 annually. Charts from Finance which take into consideration mortality rates and age reflect tile "p'resenL value cost of financing" this pension will be approximately $121,291. Page Reviewed by: Originating Dept: Costs: $121,221 Human Resources 'rotai Legal NA Budget . NA Purchasing _AA User Dept.: Current FY Risk Mgmt. _NA? CIS _ NA Funding Source; ACM ._ Advertised: ? Capt. Imp. Other NA _ Date: ? Operating Submitted by: Paper: ? Not required Affected parties ? Notified ? Not required ? Other PSI[n Appropriation Code: k46-0741 -5-,WJ 2?- 3 5 Commission Action: ? Approved ? Approved w/conditions ? Denied ? Continued to: Attuchments: Letter(s) ? None 5 ,i,, pp?uy k Human Resources Dopanmsnt 462.8870 C,I T-'Y O F •C I. E A R W A T E R POST .OFFICE BOX 4748 CLEARWATER, FLORIDA 34 618.4748 7Cr Honorable Mayor and. Members 'of the City Commission as. Trustees of the Employees' Pension Plan FROM: Pension Advisory Committee COPIES: Debbie Bailey, Payroll Services Manager Employee's File SUBJECT. Regular Pension-Donald A. Konen, Jr. DATE: January. 5, 1994 The Pension Advisory Committee received an application for regular pension . from Donald A. Konen, Jr., on December 16, 1993. Mr. Konen was employed by the City on September 12, 1973, and has been a participant in the Pension Plan since. March 13, 1974. The amount of Mr. Konen's pension will, be computed by the Finance Department at such time as his last five years of service and salary can be calculated. By motion made and, duly carried at its meeting of January 5, 1994, the Pension Advisory Committee • approved/recommended it regular pension based on years of service for Donald A. Konen, in accordance with Section 2.396 of the City Code. This pension will be effective on March Jr., A, 1994, at the beginning of the day. I Hereby certify that the Pension Advisory -Committee has approved the granting of a regular retirement pension for Donald A. Konen, Jr., and the above dates are correct. Jr'M • Nt£u?? C r1 an, %nsion Advisory Committee "Equal. Employment and A1III in aIIyo AClren C,In pIoyoI E, i r . PENSION REQUEST FORM I? Donald A. Konen, Jr, de hereby apply for retirement from the City of Clearwater General Employees' Pension Plan. My benefits date is March 13, 1974 (Entry date into pension plan) My date of hire is September 12,"1973 My birthday is March 15, 1931 My job ciaisification is Tradesworker 11 and I work in the General Services Department. Bldg. 6 Maint. Division, M y resignation date is March 25, 1994 The type of pension for which I am applying is (check only one ): Regular Pension based on years of service Job-connected Disability Pension Nan-jab-connected Disability Pension My spouse's name is: Mari-IOU Dependent children under the age of 18 and residing in my household are: (Print Child's Full Name) (Child's Date of Birth) I hereby certify all of the above io be true and correct: (Signature) December 16, 1993 (Date) (Notary Public) rta'TARY FU."LIC STATE OF FLORIDA r,iY CCg4ISsION EXP 5EPT.24,1994 Ii"vilO£D iOjU Grl??1iL I.M. 0D CITY OF CLEARWATER GENERAL EMPLOYEES' PENSION PLAN OPTIONS - GENERAL EMPLOYEES OPTION 4111: Employees can receive a.,; lump sum payment for vacation and holiday pay and 1/2 of accrued sick leave at the time of separation from the City. There will be no' $15 deduction for pension from this lump sum payment nor will this amount count as earnings in the calculation of the pension. The last day of work will be the, termination date and pension benefits will begin the following day. OPTION : Employee caa extend termination date ? by the tune due (Only available to for vacation. holiday pay, and 1/2 of accrued sick leave. employees hired Termination date will be the final day of extended time. prior to 10/1/90) 'Pension benefits will begin ' the following. day. .rwrwa,ai,rw sra*rrwrw¦virrua, Donald A. Konen, Jr. an employee of the City or Clearwater, hereby apply for. pension benefits under the General Employees' Pension Plan. I hereby certify that I fully understand the two options offered to me. I choose to retire using Option 1 and wish my benefits to be calculated under this option. I understand that once this form is signed, my decision is irrev cab e. r r EMPLOYEE'S SIGNATURE:_ ? ? ' ? 1 SOCIAL SECURITY t: 207"22-3340 ADDRESS: 2176 oak Grove Drive / `"? C. ? ,??F • ' Clearwater, FL 34624-3733 G?-- DATE: _ December 16, 1993 - 5 4 TRUSTEES OF THE EMPLOYEES' PENSION FUND Item # 4 Agenda Cover Memorandum Meeting Date: 1131 /94 Subject: Pension to be Granted Recommendation/Motion- Earl J. Stanford, Water Distribution Service Worker 11, Water Division, Public Works Department, be granted a job-connected disability pension under Section(s) 2.397 and/or 2.399 of the Employees' Pension Plan as recommended by the Pension Advisory Committee. ? and that the appropriate officials be authorized to execute same. BACKGROUND: Earl J. Stanford, Water Distribution Service Worker 11, Water Division, P u b I I c Works Department, was employed by the City on July 21, 1986, and began participating in the Pension Plan on August 11, 1989. On November 6, 1992, he injured his back while at work which is the basis for his request for this job-connected disability pension. Mr. Stanford has submitted letters from Dr. Dennis M. Lox, dated August 10, 1993, and December 23, 1993, and Dr. Clinton B. Davis Ii, dated September 3; 1993, in support of his 'request. for a disability pension. This pension will be effective at the expiration of his vacation and sick leave as prorated with Workers' Compensation. The letter from Dr. Lox states that "requirements of using vibrational equipment such as jackhammers, sledge hammers, picks and heavy lifting... predispose him to further injury. lie has sustained an underlying permanent injury as a result of his 11-6-92 work related injury." The letter from Dr. Davis states "Mr. Earl Stanford was seen ...for evaluation...relating to an 11/06/92 work-related injury while employed by the City of Clearwater Water Division ...I do not t h i n k Mr. Stanford can return to the physical demands of his previous occupation in the Water Division. This opinion comes after review of the requirements of that position where he is frequently required to use jackhammers, sledgehammers, and pick up heavy tools and objects ...He has sustained a permanent injury as a result of the 11106192 work-related injury." Page Reviewed by: Legal NA Budget ?NA Purchasing rrA Risk Mgmt. _h[.A CIS NA_ ACM Other NA Submitted by: Originating Dept Human Rcs`nurces? User Dept.: Advertised: Date: Paper: 10 Not required Affected parties ? Notified Not required Costs: $ 168.223 Total Current FY Funding Source: ? Capt. Imp. ? Operating ? Other Eemion Appropriation Code- 646-074 10- 530100-595 Commission Action: ? Approved ? Approved w/conditions ? Denied ? Continued to: Attachments: Letter(s) ? None •?•F •'6, a •1y • I .. .. .sr•`E ,, .l t 1 r .. .. W `:t •i'1,•'.[11? , `, i'i a .1 ,, ' ai.'E ?`, ( .['. :'; ,-,, ; ? of ,'fo •r .rl •'f,' n ,. . 101.•tt?i-.?t=?'; a^?r. ..'q.' layt•?®+a' 'f t ;T" •s 5+; tf..s 1?.5. 5. ."p' t'..fl: l,•?-.?,. .'! ., .l .l. ' i1' 'i'.t1•i4 iF: ... .. i yAPYiite4r> w+r MOME-+.,,. ... .. ..x-r: A?. AA Agenda Item=Earl.. Stanford Page 2 • Based on'. an average 'salary. of approximately' $20,844 over the past five years and the . formula for computing job-connected disability 'pensions, Mr, Stanford's pension, will 'approximate $15,633 annually. Charts from Finance which take into, consideration mortality rates and age reflect the,'' "Present value cost' of financing" this, pension will be approximately $168,223. Note: At the time of hire, Mr. Stanford was ` over' the ' age of 45. In 1989 when employees over t h e . age of 45 at the time : of hire were ' given an option ' to join the Pension Plan, Mr. Stanford • exercised this, option. Therefore, his pension eligibility date is August' 11, 1989. ; CITY OF C •L-E A R W A T E R POST OFFICE SOX 4748 CLEARWATER, FLORIDA-34618-4748 Human Resources Departmerd 482.8870 'IU Honorable Mayor and Members of the City Commission as Trustees of the Employees'. Pension Plan FROM: Pension Advisory Committee COPIES: Earl Stanford; Debbie Bailey, Payroll Services Manager; Risk Management SUBJECT: Pension for Earl Stanford-Jab-Connected Disability Pension DATE: January 5, 1994 The Pension Advisory Committee (PAC) received an application for disability pension from Earl Stanford on December 1, 1993. Mr. Stanford has been determined by the Pension Advisory Committee to meet t h e requirements of the Pension Plan for a job-connected disability pension, He was employed by the City on July 21, 1986, and began participating in the Pension Plan on August 11, 1989. Further, he has submitted medical documentation, copies of which are, attachred, relative to his disability which has been reviewed and approved by the PAC. By motion made and duly carried at its meeting; of January - 5, 1994, the Pension Advisory Committee approved/recommended the granting of a job-connected disability pension to Mr. Stanford in accordance with provisions of Section 2.397 of the City Code. This pension is to be effective on a date to be determined. The amount of Mr., Stanford's pension will be calculated by the Finance Department according to the formula in the Pension Plan for job-connnected disability pension at such time as his .last five years of service and salary can be computed. i hereby certify that the Pension Advisory Committee has approved the granting of a job- connected disability pension for Earl Stanford and the above dates are correct, _ __ ,1 k rn2 _ ___?_ M Ch 'rman, c?sion Advisory Committee . ''Equal Employment and Affirmative Action Employor' tow,. . r PENSION REQUEST FORM Earl Stanford do hereby apply for retirement ` from the City of Clearwater General Employees' Pension Plan. My benefits date is ,- A2922t 11, 1989 (Entry date into pension Platt) My date of hire is -,, July 21, 1986 ' My birthday is December 11, 1939 My jolt classification is Water Distribution Service Worker !-land I work • Public Works [,rater is the _ Department, , Division. My resignation date is_ to be determined • The type of pension for which I ain applying is (check only one); Regular Pension based 'on years of service x Job-connected Disability 'Pension Non-job-connected . Disability Pension My spouse's name is. Catherine Dependent childrea under the age of 18 and 'residing in my household are: '(Print Child's Full Name) (Child's Date of Birth) I I hereby certify all of the above to be true and correct: 5 (Signatilre) 4 December. 1 19 3 (Dace) , Nota - Public) KOTA"Y MQC. STATZ of F'-C,-.10A MY C01+11- :510H FXi-MCS: 5Ei'?. 24. 1994. CONDLU T#04L !-f TAnY Y4;L?.7C Zft3ZRiY RitCRS. ' CITY OF CLEARWATER GENERAL EMPLOYEES' PENSION PLAN OPTIONS - GENERAL EMPLOYEES OPTION #].: Employees. can receive a lump sum payment for vacation and holiday pay and ll2 of accrued sick leave at 'the time of separation from the City. There will be no Sco deduction for pension from this lump sum payment nor will this • amount count as earnings in the calculation of the pension. The last day of work will be the termination date And pension benefits will begin the following day. OPTION #2: Employee can extend termination date by the time due (Only available to for vacation. holiday' pay, and 112 of accrued sick leave. employees hired Termination date will be the 'final day of extended time. prior to 1011190) Pension benefits will begin the following day. ##?klrioskfo*yl#it?r##lrlltyr*k#rlrrr* I. an employee of the City of Clearwater, hereby apply for pension benefits under the General Employees' • Pension Plan, I hereby, certify that I fully understand the two options offered to me, 1 choose to retire using Option # 2 and wish my benefits to be calculated under this option. I understand that once this form is signed, my decision is irrevocable. /J EMPLOYEE'S SIGNATURE:_ 9!nJ SOCIAL SECURITY 1: 035-26-2840 ADDRESS: _ 2261 Hillwood court Clearwater,,FL 34623 n ' DATE: _ December 1, 1993 '1k1; ?a?s4?A.i?'t?jY,??.i 7''i?,'1 -... ., r ,;„'1--;" 1? ry ?4 •... I -. ?'1 r.. ? i• ''}' E 1 , Sports Medicine, .. Center j. Physical Medicine and Rehabilliazi n • Ekcwomyography - sports MedW" - Wellness RE: STANFORD, EARL To Whom 1t'May Concern: Mr. Stanford has been treated for injuries ,which, occurred as a result of an'11-C-92.,work related injury at the City of Clearwater. He is status post lumbar laminectomy but has residual complaints. His job.description has been reviewed for water distribution service worker II, and it is my opinion that Mr. Stanford is not capable of returning to work in that capacity, as it would require him to use vibrational. equipment such as jackhammers, sledge hammers and heavy lifting which I feel are. beyond his present capability and-would predispose him to further exacerbations He has sustained an underlying permanent injury as a result of the 11-6-92 work related injury. If I may be of any furthei assistance, please do not hesitate to contact me. Sincerely, DenniM. LO M. ' DMLIP'LF# 43 3 3 Dennis M. Lon, M.D. .Medical Director I1rw.114fmw. w R.i+Ailir?+ Daniel ff. Bender, M.D. e,.bd * uw kMMWW . ?( fRn" A&hw w rM ?aA?aWinoa Clearwatcr New Port R{chey Sr: Petersburg 1660 Gu1rTo Bay Blvd 5539 Mums Pultway, Sulu: 7 2299 Write Avg Nor 34611 34652 33713 443.2944 FAX. 461.0172 x41-1070 VAX: V49.1647 323-3066 FAX: 311 i - CLINTON B. DAVIS 11, M.D. MNW-4 kmkj? ALL FLORIDA, ORTHOPAEDIC ASSOCIATES 4600 - 4th Street'North • St. Petersburg, Florida 33703 (813) 527-5272 6350 Central Avenue St. Petersburg, Florida 33707 (813) 527-5272 j' September 3, 1993 City of-,Clearwater P. 0. Box 4745 Clearwater, FL 34618-4743 Re: Earl.Stanford 038069 To Whom It'May Concern Mr. Earl Stanford was seen in my office for' evaluation on 09/03/93 regarding-iniuries. relating to an 11/06/92 work--related injury while employed by the City of Clearwater Water Division. He has undergone a lumbar laminectomy and has residual symptoms and actually has.been referred for further diagnostic studies which may .show further herniated discs which may require additional operative intervention. Regardless of the outcome of possible future operative interven- :...:tion, . I -do . not think Mr. Stanford can return to the ' physical demands of his previous occupation in the Water Division. This. opinion comes after review of the requirements of that position where he is frequently required to use jackhammers, sledgehammers and pick up heavy tools and objects, often in excess of 75--100 lbs. 'He has sustained a permanent injury as a result of his 11/06/92 work--related injury. If there are further questions regarding this matter, please contact me. Sincerer, J 4t' Clinton S. Yv II, M.D. CED/nrr Enclosure cc: Earl Stanford 2161 Hillwood Court Clearwater, FL 346213 r4%• Y, at='°f''..e}? .' ` ... e. .r4,r Sa :, _,-'v?', .L, ,-C`"?i .i F' :j?•..F., F• ..",i `' . ,. .. .. . t. °!. .. ... .. dry - ... -•,. _ r' Florida Spine' & Sports Medicin'6 ' Center Physical Medicine and Rehabilitation Electromyography • Sports Medicine • Wellness August 10, 1993 City. of Clearwater RE: STANFORD, EARL To Whom It May Concern: " Mr: Stanford was. seen in the . office on 5-4-93 for injuries relating to 11-6-92 work related 'injury, while in the course of his, employment for the city of.Clearwater. He has undergone a laminectomy and has residual symptoms. Review of his job description for water distribution service worker II was reviewed and it is my opinion that Mr. Stamford is not capable. of returning to work in that capacity. Requirements of using vibrational equipment such as' jackhammers, sledge hammers, picks and heavy lifting are not in his job description and would predispose him to further injury. He has sustained an underlying permanent injury as a result of his 11-6.92 work related injury. If I may be of any further assistance, please do not hesitate to contact me. Dennis M. Lox, M. D. DML:TLF#433 cc: Mr. Earl Stamford Dennis M. Lox, M.D. Medical Director CtmW W the Ar tmm Baud of Pbys" MnbeuN uwi itembluoan Daniel H. Bender, M.D. CtM694 6y [hf AMCM94 t IN?Md d Vt<r " Medauu ends KthlbdnaNon Clearwater New Pnrt Richev St. Petersburg; 1(,6i) aulrTo Hav Blvd 5539 Marine Parkway. Suite 7 ' .299 plinth Ave North 34615 34653 ti37t] a43•;9a? rr?.\ 461.0172 1(41- 07(1 r:L\. N-11146X7 113-J tai VLNl M-2093 .7 txirgsxr WGZMlY1lb,1 r" • ;r: :. r . •+ 4 \. ... ?.:• •. r x .. t3.Y.1..l . .1.. ',sx:. .,, YJy.?s• ..- ,~ •M ? y .":• t r< .?•' 1 1?n11, kit. ?. ' FLORIDA DEPARTMENT OF LABOF D EMPLOYMENT SECURITY''?,,. ,,-f - . j?" r`` "LDIYISION,GFLWQF3KERS 4MPENSAY10ff?; ''?`•` ::" _:'`?, '?Y '"Gc6' ?Nf '?-soo- tiy7Ri cor cord*%'jour ol}Ia: for asillaWrio.. u,•,?„"f,"' "»r [//I ti.el?: 4?>In ?_. ? ...•-srch?'??•.?=.?..?,,:,rs:..'4-.Mrr'.+i6M.,ur-err.xarx`-_'k?J":i=.ttT;'?'.Ii?iT:;?'"d:r IC E O??,iN.3UR : ?.. ? ,: ?? eariuater:. -1407 P@pcrt a? diiidii Mthln 24 hOW3 (904)• 4864&4.uN,:...,?!,.. ::.L`Kn. . H+vM ?., .>+.??:w P'f 411:1?J,.Y?^M•t'i'?`??'JM•X?F ?\rZJ ??..[L... IN9 (Fiat, Middle, yrsT.e _ +sy.:?'3r•r1 : r ?. :,:_ •5:., .. - '.L•••w4 ct ..] .r •:.1n?"'.?SK"; •t7.'?'r T"'7rls? Earl-'Stanfoe&_' `f?`?`?"r_•.+?r_...-Y-.?-?;;..?-.- ..:, •...-._ ?.,._ :,,•, ..-;_'?.,. a'j.,• DlltlFalld rTNAocidertt , .. r•' S00W.r.r NUnlber ;?(?+^ar?wrys:Ktrr?•;.d'Y'r ? ?'"?. ? "Y ?e r. •-:r.~?-1? f. .,035--26 1e4o ?,?3r?•,., ,?..... z: , ; 1 1. Ilnd'iode i.. CV ..... . ' ' ? T'•' WlIi I13 ~ 4L3CLY ?'? mett3 h+ C ? , .r.ra :a. '2 554: L7B?x4N+L:I*aG? 1.= C11.rtrr PG *346?L`'i ? , _ . rY. , : fooi~?•g L- ; iir ;Tai....N-1 - 'ti: tb ''$L? e 442 f'? . •?K•• -+ • - )tKRIDE U D ANVICATE PART OF D AMMOF r _t..- :: _ ? a. . i,1 la n AMWAdion o1fV1t hdw &l at aeCOnd )oint k whifild rib i o l d t N DixtiY Sera.wke r1r,.,. WSter . . r W , s, ea po nkxn e c.) II =!'i .`7_'• =t•'-:ia ?•-is.?...?:,iy..?.'i: .r:: ^- ?'.i:.a -.:?;-. _ .,,.• DATE N! 81ITM. SEX FTC` .?-rr-•.y ?•--Sn_ " L2 t ,? 13 ' ?1 39 M ; I-] F' _• .....• .- -... .... ?. ... ?. _ ., i ._ ." '.w.."t.: n?-?::?.. IF YES, DID EMPLOYER PROVIDE MEDICAL? -- [I YES • -Q NO-z--_' ..,,,.,.FOR CARA ER'S DATE STAMP.::-'...r. RECD BY. CARRIER ;SENT TO QiVZION . •C ?;e A .A jL7oiilNlft r- ri?Mii11. 1•IIlt?'.UW?t W . y?'''¢w?i.>???.t"?•-ru'•`s•r ^. ?r.??lsi4S7??i?-"?i'•?•i :St"-3 1?.7 .s xL" :,. ?:..._ ?......... -• _ ^ , .. .,.• .. EMPLOYER INFORMATION FIRM'S NAME AND ADDRESS FEDERAL I.D. NUMBER DATE AND TIME FIRST REPORTED City of Clewwater/Watel: Division 11/06/92 3!I9 p.m. P.O. Box 474B, y r f LP 7 W.C. COVERAGE BY ' POL.ICYIMEMBER NUMBER- - CLk3a1 t t ` L$ I • ? INSURANCE CO. 9SEL F-INSURED NAME, ADDRESS. TELEPHONE OF OR SERVICE COMPANY- . INSURA CE CO WILL YOU CONTINUE TO PAY - TEL EPHON An. 813 w•er 4G2- 8 N . ap as SALARY? EXYES ? NO PLACE OF ACCIDENT 1Su*K CIM County, Stale) Fp ete! tit3co Baia 331! 7 THRWGH F30Llr Street _: Z._.__ Sanasla. FL 31370' .. ..?„ r pb l 92 Clearwat.eci PL ,.. i • 140-744-2044 RAPE OF PAY. , ? HR NAME. ADDRESS AND TELEPHONE OF PHYSICIAN OR HOSPITAL S222-3 4ER ? DAY O MO - Number of Iwura : 8 DID THE EMPLOYEE KNOWINGLY REFUSE TO USE A SA.xEIY ' ??? - in cl in C ' ' Nir of hour 1 40 ' A PPLIANCE PROVIDED BY YOU, THE EMPLOYER? ? YES ? NO 2600 US 19 ir 14orth ~? per week N DATE EMPLOYED LAST DATE EMPLLOYEE WORKED T Clearwater FL U621 umber d days 8 aer weeK 07-! 21 B6 I l l , _ .. _ PAID FOR DATE OF INJURY RETURNED TO WORK ? YES NO AUTHORIZED BY EMPLOYER d&ES ? NO YES OX NO C3 IF YES. GIVE DATE 1 ' 1 LOCATION ADDRESS WAS INJURY FATAL? ? YES NO ' IF YES. GIVE DATE OF DEATH l 1 (LOCATION 0 , IF APPLICABLE) REE WITH DESCRIPTION OF ACCIDENT? A NATURE OF BUSINESS G [.TYES ? NO IF NO ATTACH EXPLANATION Any person who. knowingly and with intent to injure. defraud or deserve Arty employer or employee, insurance company or sell-insured program, fries any statement of ti t thi th i th o eniouy" e r copy a n no ce: dam containing any false or misleading Information is guilty of a felony RI the thin dugrte. I have prwrded ' 8y Mail C) in Person D not available EQC al nature ?- EMPLOYEE SIGNATURE td avu4lbte to uqn) DATE EMPLOYER SIGNATURE DATE Uy AHHII~H INf-VHNLA11UN Carrier Audit # Location # Service Co. # Carlior File ? 1. Controverting Case--DWC•12. NOTICE OF DENIAL ATTACHED ? 2. Lost Time Case-Date of First Payment - 1. AWW - Comp Rata First day of disability ? l -Date of First Contact with Claimants © In Person ? Telephone ? Mali -Notice Rod Due to Multiple Periods of Disability, Dates Covered by First Payment ? TT.D. C1 T.P.D. Date Form Recd. ! .. l _ ? Catastrophic ? RTD. O Death ? 3. Medical Only which became a Lost Time Case. (Complete all Information in item 2 atxrve) REMARKS: ADJUSTER NAME: ADJUSTER SIGNATURE: DATE: I ADDRESS b TELEPHONE: LES Form OWCA 11ro11 =14cl hvrn 1 -nmv