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07/13/2010 4 PENSION TRUSTEES AGENDA Location: Council Chambers - City Hall Date: 7/13/2010- 9:00 AM 1. Call to Order 2. Approval of Minutes 2.1 Approve the minutes of the May 17, 2010 Pension Trustees meeting as submitted in written summation by the City Clerk. Attachments 3. Pension Trustee Items 3.1 Approve New Hires for Membership in Pension Plan Attachments 3.2 Approve Regular Pensions as Submitted by Employees Attachments 3.3 Approve Vested Pension as Submitted by Employee Attachments 3.4 Approve changing the performance measurement benchmark for ING Investment Management Co. (ING IM) from the Standard and Poors 500 Index to the Russell 1000 Growth Index and authorize the appropriate officials to execute same. Attachments 4. Other Business 5. Adjourn Meeting Date:7/13/2010 Pension Trustees Agenda Council Chambers - City Hall SUBJECT / RECOMMENDATION: Approve the minutes of the May 17, 2010 Pension Trustees meeting as submitted in written summation by the City Clerk. SUMMARY: Review Approval: 1) Clerk Cover Memo Item # 1 Attachment number 1 Page 1 of 2 TRUSTEES OF THE EMPLOYEES' PENSION FUND MEETING MINUTES CITY OF CLEARWATER May 17, 2010 Present: Chair/Trustee Frank Hibbard, Trustee George N. Cretekos, Trustee John Doran, Trustee Paul Gibson, and Trustee Bill Jonson. Also William B. Horne II - City Manager, Jill S. Silverboard - Assistant City present: Manager, Rod Irwin - Assistant City Manager, Pamela K. Akin - City Attorney, Cynthia E. Goudeau - City Clerk, and Rosemarie Call - Management Analyst. Unapproved To provide continuity for research, items are in agenda order although not necessarily discussed in that order. 1. Call to Order - Chair/Trustee Frank Hibbard The meeting was called to order at 9:12 a.m. at City Hall. 2. Approval of Minutes 2.1 Approve the minutes of the April 13, 2010 ension Trustees meeting as submitted in written summation by the Citv Clerk. Trustee Paul Gibson moved to approve the minutes of the April 13, 2010 Pension Trustees meeting as submitted in written summation by the City Clerk. The motion was duly seconded and carried unanimously. 3. Pension Trustee Items 3.1 Employees listed b approved for acceptance into th City of Clearwater ploy e°s Pension Plan. Pension Trustee 2010-05-17 Item #11 Attachment number 1 Page 2 of 2 Name, Job. Class, & Dept./Div Hire Pension Date Elig.Date Alexander Lane, Public Services Technician I/Public 3/1/10 3/1/10 Services Brett Jennings, Solid Waste Worker/Solid 11/23/09 3/1/10 Waste *Charles King Solid Waste Worker/Solid 10/27/09 3/1/10 , Waste **Geri West, Police Communications Operator 3/1/10 3/1/10 Trainee/Police James Ford, Public Utilities Technician I/Public 3/1/10 3/1/10 Utilities Denise Hirons, Police Communications 3/1/10 3/1/10 Operator/Police Vincenza Gatti, Property Clerk/Police 3/15/10 3/15/10 .. Lisa Pennamacoor, Police Information Technician 3/15/10 3/15/10 /Police Ryan Reilly, Parks Service Technician I/Parks & Recreation 3/15/10 3/15/10 Originally hired 11/23/09 as temporary; transferred to permanent and pension eligible as of 3/1/10. ** Originally hired 10/27/09 as temporary; transferred to permanent and pension eligible as of 3/1/10. Trustee Bill Jonson moved to accept the Employees listed into the City of Clearwater Employee's Pension Plan. The motion was duly seconded and carried unanimously. 4. Other Business - None. 5. The meeting was adjourned at 9:13 a.m. Chair Employee's Pension Plan Trustees Attest City Clerk Pension Trustee 2010-05-17 Item #21 Meeting Date:7/13/2010 Pension Trustees Agenda Council Chambers - City Hall SUBJECT / RECOMMENDATION: Approve New Hires for Membership in Pension Plan SUMMARY: Pension Name, Job. Class, & Dept./Div. Hire Date Elig Date Christopher Buehler, WWTP Oper. Trne./Pub. Util. 5/8/10 5/8/10 Robert Shulmister, WWTP Oper. Trne./Pub. Util. 5110110 5110110 Gregg Lonkey, Marine Fac. Oper./Marine & Aviation 4/14/07 5/8/10 Frederick Hemerick, Wtr. Treat. Pl. Chief Oper./Pub. Util. 5/24/10 5/24/10 Originally hired as part-time on 4/14/07; status changed to full-time and pension eligible as of 5/8/10 Review Approval: 1) Clerk Cover Memo Item # 2 Meeting Date:7/13/2010 Pension Trustees Agenda Council Chambers - City Hall SUBJECT / RECOMMENDATION: Approve Regular Pensions as Submitted by Employees SUMMARY: Richard Niemiller, Public Utilities Supervisor H, Public Utilities Department, was employed by the City on April 4, 1983, and his pension service credit is effective on that date. His pension will be effective June 1, 2010. Based on an average salary of approximately $62.013 per year over the past five years, the formula for computing regular pensions, and Mr. Niemiller's selection of the Joint & Survivor Annuity, this pension will approximate $46,301 annually. John Walton, Service Dispatcher, Gas Department, was employed by the City on August 26, 1981, and his pension service credit is effective on that date. His pension will be effective June 1, 2010. Based on an average salary of approximately $42,073 per year over the past five years, the formula for computing regular pensions, and Mr. Walton's selection of the 100% Joint & Survivor Annuity, this pension will approximate $32,645 annually. Stephen Bigley, Recreation Supervisor I, Parks & Recreation Department, was employed by the City on May 20, 1981, and his pension service credit is effective on that date. His pension will be effective June 1, 2010. Based on an average salary of approximately $56,574 per year over the past five years, the formula for computing regular pensions, and Mr. Bigley's selection of the Joint & Survivor Annuity, this pension will approximate $33,929 annually. James Nungester, Solid Waste Equipment Operator, Solid Waste/General Services Department, was employed by the City on August 13, 1990, and his pension service credit is effective on that date. His pension will be effective September 1, 2010. Based on an average salary of approximately $44,423 per year over the past five years, the formula for computing regular pensions, and Mr. Nungester's selection of the Joint & Survivor Annuity, this pension will approximate $24,494 annually. William Lueders, Recreation Specialist, Parks & Recreation Department, was employed by the City on September 26, 1984, and his pension service credit is effective on that date. His pension will be effective June 1, 2010. Based on an average salary of approximately $54,108 per year over the past five years, the formula for computing regular pensions, and Mr. Lueders' selection of the 100% Joint & Survivor Annuity, this pension will approximate $36,969 annually. Bruno Yankus, WastewaterTreatment Plant Operator A, Public Utilities Department, was employed by the City on July 15, 1985, and his pension service credit is effective on that date. His pension will be effective June 1, 2010. Based on an average salary of approximately $56,704 per year over the past five years, the formula for computing regular pensions, and Mr. Yankus' selection of the 100% Joint & Survivor Annuity, this pension will approximate $37,977 annually. Michael Harrington, Machinist/Fabricator, Public Utilities Department, was employed by the City on October 20, 1980, and his pension service credit is effective on that date. His pension will be effective August 1, 2010. Based on an average salary of approximately $59,081 per year over the past five years, the formula for computing regular pensions, and Mr. Harrington's selection of the 75% Joint & Survivor Annuity, this pension will approximate $48,444 annually. David Doyle, Police Communications Supervisor, Police Department, was employed by the City on January 28, 1 g anfloi pension service credit is effective on that date. His pension will be effective June 1, 2010. Item # 3 Based on an average salary of approximately $59,923 per year over the past five years, the formula for computing regular pensions, and Mr. Doyle's selection of the 100% Joint & Survivor Annuity, this pension will approximate $40,998 annually. Edward Turnbull, Fleet Mechanic, Solid Waste/General Services Department, was employed by the City on February 4, 1980, and his pension service credit is effective on that date. His pension will be effective June 1, 2010. Based on an average salary of approximately $62,138 per year over the past five years, the formula for computing regular pensions, and Mr. Turnbull's selection of the 10-year Certain & Life Annuity, this pension will approximate $51,092 annually. Thomas King, Solid Waste Supervisor II, Solid Waste/General Services Department, was employed by the City on April 25, 1980, and his pension service credit is effective on that date. His pension will be effective June 1, 2010. Based on an average salary of approximately $57,562 per year over the past five years, the formula for computing regular pensions, and Mr. King's selection of the 100% Joint & Survivor Annuity, this pension will approximate $46,920 annually. Robert Gundel, Fleet Mechanic Supervisor, Solid Waste/General Services Department, was employed by the City on May 5, 1980, and his pension service credit is effective on that date. His pension will be effective June 1, 2010. Based on an average salary of approximately $66,750 per year over the past five years, the formula for computing regular pensions, and Mr. Gundel's selection of the 100% Joint & Survivor Annuity, this pension will approximate $54,160 annually. Roger Hooey, Wastewater Treat Plant Chief Operator, Public Utilities Department, was employed by the City on December 20, 1979, and his pension service credit is effective on that date. His pension will be effective June 1, 2010. Based on an average salary of approximately $65,672 per year over the past five years, the formula for computing regular pensions, and Mr. Hooey's selection of the Joint & Survivor Annuity, this pension will approximate $54,937 annually. Robert VanDuyne, Design & Mapping Technician, Engineering Department, was employed by the City on April 14, 1980, and his pension service credit is effective on that date. His pension will be effective July 1, 2010. Based on an average salary of approximately $48,415 per year over the past five years, the formula for computing regular pensions, and Mr. Van Duyne's selection of the Joint & Survivor Annuity, this pension will approximate $40,116 annually. Brian McLaughlin, Police Communications Supervisor, Police Department, was employed by the City on May 23, 1977, and his pension service credit is effective on July 30, 1977. His pension will be effective August 1, 2010. Based on an average salary of approximately $53,584 per year over the past five years, the formula for computing regular pensions, and Mr. McLaughlin's selection of the 100% Joint & Survivor Annuity, this pension will approximate $46,769 annually. Cara Cooper, Police Service Technician, Police Department, was employed by the City on May 2, 1978, and her pension service credit is effective on that date. Her pension will be effective August 1, 2010. Based on an average salary of approximately $44,317 per year over the past five years, the formula for computing regular pensions, and Ms. Cooper's selection of the Joint & Survivor Annuity, this pension will approximate $39,195 annually. Marietta Cooper, Police Service Technician Supervisor, Police Department, was employed by the City on October 21, 1974, and her pension service credit is effective on that date. Her pension will be effective July 1, 2010. Based on an average salary of approximately $50,283 per year over the past five years, the formula for computing regular pensions, and Ms. Cooper's selection of the Joint & Survivor Annuity, this pension will approximate $49,354 annually. Theresa Coffey, Accounting Technician, Library Department, was employed by the City on May 5, 1980, and her pension service credit is effective on that date. Her pension will be effective July 1, 2010. Based on an average salary of approximately $39,212 per year over the past five years, the formula for computing regular pensions, and Ms. Coffey's selection of the 50% Joint & Survivor Annuity, this pension will approximate $33,309 annually. Virginia Costa, Personnel/Payroll Technician, Fire Department, was employed by the City on September 29, 1980, and her pension service credit is effective on that date. Her pension will be effective October 1, 2010. Based on an average salary of approximately $40,693 per year over the past five years, the formula for computing regOwT64wi-ons, and Ms. Costa's selection of the 50% Joint & Survivor Annuity, this pension will approximate $34,415 annually. Item # 3 Gwen Hollander, Legal Staff Assistant, Legal Department, was employed by the City on August 12, 1999, and her pension service credit is effective on that date. Her pension will be effective July 1, 2010. Based on an average salary of approximately $40,739 per year over the past five years, the formula for computing regular pensions, and Ms. Hollander's selection of the Joint & Survivor Annuity, this pension will approximate $12,112 annually. Elizabeth Robinson, Library Assistant, Library Department, was employed by the City on December 23, 1996, and her pension service credit is effective on that date. Her pension will be effective June 1, 2010. Based on an average salary of approximately $26,960 per year over the past five years, the formula for computing regular pensions, and Ms. Robinson's selection of the Joint & Survivor Annuity, this pension will approximate $9,964 annually. Billy McKeever, Tradesworker, Parks & Recreation Department, was employed by the City on October 17, 1994, and his pension service credit is effective on that date. His pension will be effective September 1, 2010. Based on an average salary of approximately $34,054 per year over the past five years, the formula for computing regular pensions, and Mr. McKeever's selection of the Joint & Survivor Annuity, this pension will approximate $14,630 annually. Dwayne Vaughan, Firefighter, Fire Department, was employed by the City on January 10, 1983, and his pension service credit is effective on that date. His pension will be effective June 1, 2010. Based on an average salary of approximately $75,573 per year over the past five years, the formula for computing regular pensions, and Mr. Vaughan's selection of the 100% Joint & Survivor Annuity, this pension will approximate $55,740 annually. Gregory Stewart, Police Sergeant, Police Department, was employed by the City on November 3, 1989, and his pension service credit is effective on that date. His pension will be effective June 1, 2010. Based on an average salary of approximately $79,833 per year over the past five years, the formula for computing regular pensions, and Mr. Stewart's selection of the 100% Joint & Survivor Annuity, this pension will approximate $44,344 annually. Terence Kelly, Police Officer, Police Department, was employed by the City on November 3, 1989, and his pension service credit is effective on that date. His pension will be effective June 1, 2010. Based on an average salary of approximately $72,411 per year over the past five years, the formula for computing regular pensions, and Mr. Kelly's selection of the Life Annuity, this pension will approximate $43,735 annually. Scott Dawson, Police Officer, Police Department, was employed by the City on September 24, 1990, and his pension service credit is effective on that date. His pension will be effective October 1, 2010. Based on an average salary of approximately $72,979 per year over the past five years, the formula for computing regular pensions, and Mr. Dawson's selection of the 100% Joint & Survivor Annuity, this pension will approximate $39,595 annually. Section 2.393 provides for normal retirement eligibility when a participant has completed thirty years of credited service, has reached age 55 and completed twenty years of credited service, or has reached age 65 and completed ten years of credited service. Section 2.393 also provides for normal retirement eligibility when a participant has completed twenty years of credited service or has reached age 55 and completed ten years of credited service in a type of employment described as "hazardous duty" and further defines service as a Firefighter, Police Sergeant, and Police Officer as meeting the hazardous duty criteria. Mr. Niemiller, Mr. Walton, Mr. Bigley, Mr. Nungester, Mr. Lueders, Mr. Yankus, Mr. Harrington, and Mr. Doyle qualify under the age 55 and 25 years of service criteria. Mr. Turnbull, Mr. King, Mr. Gundel, Mr. Hooey, Mr. Van Duyne, Mr. McLauglin, Ms. Cooper, Ms. Cooper, Ms. Coffey, and Ms. Costa qualify under the 30 years of service criteria. Ms. Hollander, Ms. Robinson, and Mr. McKeever qualify under the age 65 and 10 years of service criteria. Mr. Vaughan, Mr. Stewart, Mr. Kelly, and Mr. Dawson qualify under the hazardous duty criteria. Review Approval: 1) Clerk Cover Memo Item # 3 HLCdGnfnenL nUfnUer I Page 1 of 116 CITY OF CLEARiiv'A TER EMPL O PEES' SEPARA T/ON PA Y PREFERENCES PREFERENCE #? Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. I, C' `G?? ?+ ?i I?? an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # r and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation sick floaters bonus hours Lump Sum ?•1 vacation .7 6 I, 3y sick S2 y' Q floaters " bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. EMPLOYEE'S SIGNATURE: SOCIAL SECURITY #: WITNESSES: ADDRESS: ©? 3 ?C1 ?`r? / vf?or? , ?L 3 y6S V PHONE: Revised 1/02 Form #9900-0008 -W '7'7/-06?'d DATE: 6 File Name: Employee Separation Pay Pref Item # 3 ruidauneiii IIUIIIDUI i Page 2 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM I, r\ ig, a ra N , e r>? i // et- do hereby apply for retirement under the City of Clearwater General Employees' Pension Plan. Job Classificati ?? '? ?1 ?S TUJQ 11V SUK- Sex: 0 F Department: es ivision: Benefits Date: Date of Hire: y ` Date of Birth: Resignation Date: 0 Spouse's Name: `-' < <'????' Sex: M Spouse's Date of Birth: The type of pension for which I am applying is (check only one): Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #6) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 - Joint and Survivor Annuity The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Ann city The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary's estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 50% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% Join & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Item # 3 HLCaGnfnenL nUfnUer I Page 3 of 116 Qptmon n jo(')% joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)j I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 6) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) I understand that once my first pension check is received, my decision on this option is irrevocable. Option #: 1 Descr' tion: Joint and Survivor Annuity . X // I - - Employee's Signature: . Date: Ay / G Dependent children under the age of 18 and residing in my household are: Child's Name Sex Date of Birth If taking Option 2 sign below: Option #: -2- Description: Life Annuity Employee's Signature: Date: If taking Option 3 4 5 or 6 fill in beneficiary information and sign below: Option #: Description: My designated beneficiary is: Name: Date of Birth: Sex M F Social Security Number: Phone Number: Address: Employee's Signature: Date: STATE OF FLORIDA The foreg ing i strument was a now edgedQbefor me this COUNTY OF PINELLAS {S //0 by Ij C?&Il3C /r ,(?1i //1f-*' who is personally known to me or who has provided as identif' a ion an who did/dicnot t n a Notary Public (Sig ature) Name of Notary Printed My Commission expires: NOTARY PUBLIC-SW Ford Deborah L Commission #DD763426 Expires-ncNIA?ING53426 co., INc2012 Rev. 4/08 3oriDEn THxU An ntY Form #9900-0009 File Name: Pension Entitlement Option Form Item # 3 Attachment number 1 Page 4 of 116 Estimated Pension Worksheet Richard Niemiller LAST DATE PAID: 5/28/2010 BENEFITS DATE 4/4/1983 CREDITED SERVICE 27.1500 Signature: t - Qa41(-Wj Date: S qI/Ij- GROSS CALENDAR PENSION YEAR EARNINGS 2005 $59,209.93 2006 $62,238.48 2007 $62,656.95 2008 $61,221.54 2009 $64,738.58 $310,065.48 (5 Year Total) 5/ $62,013.10 (Yearly Avg) 12/ $5,167.76 (Monthly Avg) x 0.0275 (Benefit Rate) x 27.1500 (Yrs of Service) $3,858.38 (Est Mtly Pension) Item # 3 Hnacnmem numoer i Page 5 of 116 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors 18-May-10 sm ESTIMATE c1ract01 Version: Employee Name: Richard Niemiller 1-4-96 Employee Date of Birth: 1 22 1949 Marital Status: m Spouse Date of Birth: 11 21 1947 Beneficiary Date of Birth: 11 21 1947 Benefit Commencement Date : 6 1 2010 Estimated Monthly Normal Reti rement Benefit: $3,858.38 Estimated Monthly Actuarial Equivalent Adjustment Factors: Benefit Option 1 Normal Form 1.00000 $3,858.38 Option 2 Life Annuity 1.09593 $4,228.53 Option 3 10 Year Certain 1.06502 $4,109.24 Option 4 50% J&S 1.03394 $3,989.33 Option 5 75% J&S 1.00550 $3,879.61 Option 6 100% J&S 0.97858 $3,775.75 ESTIMATE Item # 3 Attachment number 1 Page 6 of 116 COT Y OF CL EAR YVA T ER EMPL O YEES' SEPARA T/ON PA Y PREFERENCES PREFERENCE #I Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. i, 1 dh-l,EO?4-?? an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation sick floaters J bonus hours Lump Sum 3 S? vacation 02779' 5?sick floaters / 0 0 bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. EMPLOYEE'S SIGNATURE:- SOCIAL SECURITY #: - - - WITNESSES: ADDRESS: S (a / YES CCG lUr• J Z2,L PHONE: 7 L7 D ATE: 7 //y Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 3 Attachment number 1 Page 7 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM I , ?/ o' h ?1 L-lJQ 1 Tan .[L of Clearwater General Employees' Pension Plan. Job Classification: s Y. L) 1 G(t_ Department: Benefits Date: ?f d? k Date of Birth: 3/ S? Sex: 0 F viviaiui1. Date of Hire: :?; a 4, Resignation Date: F11 7 / Q Spouse's Name: h G Y-0;1- W o 1'-4n Sex: M (fli Spouse's Date of Birth: N a 7 fo The type of pension for which I am applying is (check only one): J, Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #6) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 - Joint and Survivor Annuity The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Annuity The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary's estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 50% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75%, Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Item # 3 do hereby apply for retirement under the City ?) i*S Da4c A e .,, Hnacnmem numDer i Page 8 of 116 ,option 6 - 1100% Join' & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 6) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) I understand that once my first pension check is received, my decision on this option is irrevocable. Option #: I Employee's Signature: Date: Dependent children under the age of 18 and residing in my household are: Child's Name Sex Date of Birth If taking Qption 2 sign below Option #: 2 Description: Life Annuity Employee's Signature: Date: Option #: !G? Description: y a a "A -F v??.) ° vow /If Y7 h My desig ed beneficiary is, Name: Ct i?crv? cl 14-CM Date of Rirth• ? /a -7 Al Sex M 6 Social Security Number:. Phone Number: 7 D -7/ y?S" oZ -70 9 Address: S /?1 <<S CIO 0/ eUY-,.Aj a?Pr ? 337SI Employee's Signature: Date: // 7 /10 STATE OF FLORIDA COUNTY OF PINELLAS e foreg 1ng i strument was acknowledged before me.this 7 J ? LO 4d p ^ R yi /0 by 2 who is personally known to me or who has provided k a oath. aside ry I ic? and who di /did no J i'1 - /? Notary Public (Signature) i t d f N t P t A N O am Y C r n e o o ary e My Commission expires:,NaTAgy pllf UC-STATE OF FLORIDA Deborah L. Ford Commission #DD763426 ' Expires: MAY 15, 2012 > ); DED TIIRU KILANTIC BONDING CO., INC. Rev. 4/08 Form #9900-0009 File Name: Pension Entitlement Option Form Description: Joint and Survivor Annuity Item # 3 ruidauneiii IIUIIIuei i Page 9 of 116 Estimated Pension Worksheet John Walton LAST DATE PAID: 5/31/2010 BENEFITS DATE 8/26/1981 CREDITED SERVICE 28.7639 Signature: &4k?d & Date: O GROSS CALENDAR PENSION YEAR EARNINGS 2005 $43,937.44 2006 $44,356.77 2007 $41,825.78 2008 $39,303.78 2009 $40,942.45 $210,366.22 (5 Year Total) 5/ $42,073.24 (Yearly Avg) 12/ $3,506.10 (Monthly Avg) x 0.0275 (Benefit Rate) x 28.7639 (Yrs of Service) $2,773.35 (Est Mtly Pension) Item # 3 HLCaU111T1e11L HUITIDer I Page 10 of 116 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors 10-May-10 sm ESTIMATE clract01 Version: Employee Name: John Walton 1-4-96 Employee Date of Birth: 3 31 1955 Marital Status: M Spouse Date of Birth: 4 27 1956 Beneficiary Date of Birth: 4 27 1956 Benefit Commencement Date : 6 1 2010 Estimated Monthly Normal Reti rement Benefit: $2,773.35 Actuarial Equivalent Adjustment Factors: Option 1 J&S Annuity 1.00000 Option 2 Life Annuity 1.08444 Option 3 10 Year Certain 1.06880 Option 4 50% J&S 1.03008 Option 5 75% J&S 1.00489 Option 6 100% J&S 0.98091 ESTIMATE Estimated Monthly Benefit $2,773.35 $3,007.54 $2,964.17 $2,856.77 $2,786.91 $2,720.39 Item # 3 Attachment number 1 Page 11 of 116 CITY OF CLEARWA TER EMPL O YEES' SEPARA TION PA Y PREFERENCES PREFERENCE #I Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. an employee of the City of Clearwater, hereby apply for pension benefits under the City Employees' Pension Plan. I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # -? and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation sick floaters bonus hours Lump Sum ?? ` vacation 0 sick 9'0 floaters ic)- o- a bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. EMPLOYEE'S SIGNATURE: WE??P SOCIAL SECURITY #• WI NESSES: ADDRESS: S c)? y 3 3ca GA A- , 'S C__ C Y-? - k4,r r s b c//-4 , rL 3 :y ? a T PHONE: /?q9-t?,Y3,?,-DATE: Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 3 Attachment number 1 Page 12 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM I, do hereby apply for retirement under the City of Clearwater neral Employee ,tension Plan. Job Class ificatio ? PC eu'M d? Sjl9et-01. 0,- Sexo F Department: ae o-ecre Division: Benefits Date: 5 Cj Date of Hire: Date of Birth: /11I I Resignation Date: S / CU Spouse's Name: Sex: M F Spouse's Date of Birth: The type of pension for which I am applying is (check only one): Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #6) shall be computed to be the Actuarial Equivalent of the normal benefit- Option 1 - Joint and Survivor Annuity The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Annuity The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] Option 3 - 10 Year Certain & Life Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies bbbfore. 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary's estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 50% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Item # 3 Httachment number Page 13 of 116 mention 6 - ? iii /? ioini i4 tiarvivor Annuit: - (must designate a beneficiary] The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)J I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 6) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) I understand that once my first pension check is received, my decision on this option is irrevocable. Option #: ? cription: Joint and Survivor Annuity Employee's Signature: Date: .S ? ? ? ? Dependent children under the age of nd residing in my household are: Child's Name Sex Date of Birth tf taking Option 2 sign below: Option #: 2 Description: Life Annuity Employee's Signature: Date: If takina Option 3, 4, 5, or 6 fill in beneficiary information and sian below: Option #: Description: My designated beneficiary is: Name: Date of Birth: Sex M F Social Security Number: Phone Number: Address: Employee's Signature: Date: STATE OF FLORIDA The foreg ing ins ument was acknowledgLed bef me his COUNTY OF PINELLAS S' ?? ? (J by ?? /I ?, ?' who is personally known to me or who has provided as identifi tion ? di didk ath. Notary Public (Si ature)/ d?h • ?? Name of Notary Printed h'CTA,?yP My Commission expires: "' -. ??IC? e6orak oF?o?.D.? Commissiob #L' FOrd aoi;?'"„••' ?xpfres: ?D?634 Rev. 4/08 ? 77tRUAT1.?.IC RC??1C ®©2?y?2 Form #9900-0009 File Name: Pension Entitlement Option Form Item # 3 HLCaUF1FT1e11L HUITIDer I Page 14 of 116 11 Estimated Pension Worksheet Stephen Bigley LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 5/31/2010 8/10/1988 21.8083 Signature: Date: GROSS CALENDAR PENSION YEAR EARNINGS 2005 $52,417.89 2006 $54,506.55 2007 $56,678.44 2008 $58,916.18 2009 $60,351.90 $282,870.96 (5 Year Total) 5/ $56,574.19 (Yearly Avg) 12/ $4,714.52 (Monthly Avg) x 0.0275 (Benefit Rate) x 21.8083 (Yrs of Service) $2,827.44 (Est Mtly Pension) Item # 3 ,emu-ui-I II IIUIi I-I i Page 15 of 116 CI TY Orr CLEAR'vVA I 'ER EMPL OYEES' SERA RA T/ON PA Y PREFERENCES PREFERENCE #1 Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. VV1e5 V'1QI C'S e? an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # - i_ and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation sick floaters bonus hours Lump Sum oZo1? vacation /0-7, q6 sick floaters bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. EMPLOYEE'S SIGNATURE: I.l (.l,-? SOCIAL SECURITY # WIT ESSES: ADDRESS: '? ??? f PHONE: Revised 1/02 Form #9900-0008 (2/f 'rwc, ?f.-- IIY 6, 70V t' 0'& DATE: S-// q lo File Name: Employee Separation Pay Pref Item # 3 Page 16 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM I, 1--1 C4 M C> 71Ce , do hereby apply for retirement under the City of Clearwater General Employees' Pensg)n Plan. Job Classific n• S0 /1 a S-k Cf V rn Pi17+ f vcc v SexG F Department: I I'd 4S)LC_ bra F?-, Division: Benefits Date: U Date of Hire: Z/3/9p Date of Birth: /a 30 1 7. Resignation Date: // ? /11 /0 Spouse's Name: . -a V r dry V U ?Ck-. Sex: M Spouse's Date of Birth: 3/.,/ N-3 L11 The type of pension for which I am applying is (check only one): ?_ Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #6) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 -Joint and Survivor Annuity The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Annuity The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] Option 3 - 10 Year Certain & Life Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary's estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 50% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Item # 3 XiCd(, Page 17 of 116 Option b - 100 % join" & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 6) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) I understand that once my first pension check is received, my decision on this option is irrevocable. Option #: I Description: Joint and Survivor Annuity Employee's Signature: Date: s ?U Dependent children under the age of 18 and residing in my household are: Child's Name Sex Date of Birth If taking Option 2 sign below: Option #.- 2 Description: Life Annuity Employee's Signature: Date: Option #: My designated beneficiary is: Name: Social Security Number: Address: Description: Date of Birth: Sex M F Phone Number-. Employee's Signature: Date: STATE OF FLORIDA The foreg ing in trument was acknowledged/ before me this COUNTY OF PINELLAS ?J U by _ R l? C5 /vim r15 CS 7-C'/. who is personally known to me or who has provided as identi c tion n who di /diq,26 ,?Ia e n oat Notary Public (Signatu e) rGl. ?' ?? Name of Notary Printed NOTARY PUBLIC-STATE OF FLORMA My Commission expires: Deborah T . Fore: Commission # DD763c2 ' Expires: MAY 15, 2GI BONDED THRU ATLAti ITC BONDING CO., INC Rev. 4/08 Form #9900-0009 File Name: Pension Entitlement Option Form Item # 3 ruidauneiii IIUIIIuei i Page 18 of 116 Estimated Pension Worksheet James Nungester LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 8/31/2010 8/13/1990 20.0500 Signature: Date: / ,10 GROSS CALENDAR PENSION YEAR EARNINGS 2004 $43,000.47 2006 $43,041.94 2007 $43,990.50 2008 $45,702.52 2009 $46,378.11 $222,113.54 (5 Year Total) 5/ $44,422.71 (Yearly Avg) 12/ $3,701.89 (Monthly Avg) x 0.0275 (Benefit Rate) x 20.0500 (Yrs of Service) $2,041.13 (Est Wily Pension) Item # 3 Page 19 of 116 Cl T Y OF CLEARVV104 T ER EMPL O YEES' SEPARA T/ON PA Y PREFERENCES PREFERENCE #1 Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. L ecle?s , an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. I hereby certify that I f fly understand the preferences offered to me. I choose to retire using separation pay preference # and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation sick floaters bonus hours Lump Sum vacation 90 3°-73 sick floaters bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. EMPLOYEE'S SIGNATURE: SOCIAL SECURITY #: WITNESSES: ADDRESS: L/ 7 S.Z MPadcnus-wee-4 k--7-. 14?J /--i? SY6,?-3 PHONE: ?? 7/3 - 673 C, DATE: 0 o Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 3 nrrar;rn Page 20 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM i do hereby apply for retirement under the City of Clearwater General Employees' Pension Plan. Job Classification, ec Pte) / (' C/ f ST Sex:Q Department: +- ea 11'0A Division: l y S 1` ccvPa, 41 Benefits Date: `? Lx 4P Date of Hire: ? Date of Birth: Resignation Date: U d Spouse's Name: 6_k_Cfq k oeC%(P?S Sex: M Spouse's Date of Birth: 9 1 -7 1 to 1 The type of pension for which I am applying is (check only one): _ Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #6) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 - Joint and Survivor Annuity The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Annuity The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary's estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 50% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% Joint R. Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Item # 3 hq?-/,. HLCaGnfnenL nUfnUer I Page 21 of 116 Option 6 - 100% joint & Survivor Annieity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 6) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) I understand that once my first pension check is received, my decision on this option is irrevocable. Option #: 2 Employee's Signature: Description: Joint and Survivor Annuity Dependent children under the age of 18 and residing in my household are: Child's Name Sex Date: Date of Birth If taking Option 2 sign below: Option #: 2 Description: Life Annuity Employee's Signature: Date: If taking Option 3, 4, 5, or 6_fill _in_beneficiarv information and sian below: Option #: G Description:- /DO °]l'c) CJ"O d •'1`? °? .?U?'?? ?' ?? rI U, My desig a d benefic ry Name: Kk Keh U Cd?'5 Date of Birth- l7 6 Sex M 0 Social Security Number: Phone Number: 7,:? 7 3 26- 6 7 34 Address: y 7 S / , r ?? Ul?-? f GtJ e?? - -Aje L,-.0 a r`?" ?:he u , rC 3 y6s? Employee's Signature: k ?`16pGJ>? Date: S1o20110 STATE OF FLORIDA f The forego' g instrument was acknowledged before me this COUNTY OF PINELLAS ?-(1 !U by W / I 1 1'q vn 4 u P PyS' who is personally known to me or who has provided as identif tion and who dill/did pit ak UIth. ?`?l/C/. f/?1!/ Notary Public \ et) (Signature) - J d fG-A L- O 1"4 Name of Notary Printed My Commission expires: NOTARY 111BLI4STATE OF FLORID % Deborah L. Ford '-Commission #D D763_2 Rev. 4/08 „ -` Expires: NAY 15, 201? Form #9900-0009 13ONDFn Txxv nn :LV rTC sonata c i)., File Name: Pension Entitlement Option Form Item # 3 Page 22 of 116 Estimated Pension Worksheet William Lueders LAST DATE PAID: 5/20/2010 BENEFITS DATE 9/26/1984 CREDITED SERVICE 25.6500 Signature: Date: ho GROSS CALENDAR PENSION YEAR EARNINGS 2005 $50,628.73 2006 $52,661.15 2007 $54,380.08 2008 $55,978.38 2009 $56,891.35 $270,539.69 (5 Year Total) 5/ $54,107.94 (Yearly Avg) 12/ $4,509.00 (Monthly Avg) x 0.0275 (Benefit Rate) x 25.6500 (Yrs of Service) $3,180.54 (Est Mtly Pension) Item # 3 Attachment number 1 Page 23 of 116 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors 20-May-10 sm ESTIMATE clract01 Version: Employee Name: William Lueders 1-4-96 Employee Date of Birth: 3 3 1951 Marital Status: m Spouse Date of Birth: 9 7 1961 Beneficiary Date of Birth: 9 7 1961 Benefit Commencement Date : 6 1 2010 Estimated Monthly Normal Reti rement Benefit: $3,180.54 Actuarial Equivalent Adjustment Factors: Option 1 Normal Form 1.00000 Option 2 Life Annuity 1.14887 Option 3 10 Year Certain 1.12332 Option 4 50% J&S 1.05107 Option 5 75% J&S 1.00816 Option 6 100% J&S 0.96862 ESTIMATE Estimated Monthly Benefit $3,180.54 $3,654.01 $3,572.75 $3,342.98 $3,206.51 $3,080.74 Item # 3 --ui-I II IIUIi I-I i Page 24 of 116 ^1 T Y OF CLEAR'VVA TER EMPL OYEES' SEPARA T/ON PA Y PREFERENCES PREFERENCE #1 Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. SV 0V1 U Y L in [ US an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # ?- and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation sick floaters bonus hours Lump Sum c;2©7. 17 vacation -707, 9°'Z sick 2(1-0 floaters 0 bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. EMPLOYEE'S SIGNATURE: -x- SOCIAL SECURITY #: WI NESSES: ADDRESS: ?. o' 8d K py/ kL44-??4 Lq n J o Lakes rL 3,/4, 3 S PHONE: ?SI3/o?IS-?F7/0 DATE: -5 /a/ /0 Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 3 Page 25 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM I, ru n p v do hereby apply for retirement under the City of Clearwater General Employees' Pension Plan. Job Classification :? 0 / Sex:[ F Department V I c U? 'ri Division: Benefits Date: -7 11 Date of Hire: Date of Birth: I v /( S Resignation Date: Spouse's Name: h G 4 h K(iS Sex: M Spouse's Date of Birth: 02 /G .S The type of pension for which I am applying is (check only one): X Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #6) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 - Joint and Survivor Annuity The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Annuity The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] Option 3 - 10 Year Certain & Life Annuity, - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary's estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 50% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Item # 3 ruidauneiii IIUIIIDUI i Page 26 of 116 Option e - 100% join' & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 6) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) I understand that once my first pension check is received, my decision on this option is irrevocable. Option #: 1 Employee's Signature: Description: Joint and Survivor Annuity Dependent children under the age of 18 and residing in my household are: Child's Name Sex Date: Date of Birth If taking Option 2 sign below: Option #: 2 Description: Life Annuity Employee's Signature: Date: 6 Option #: 6o Description: P1 .7u f My designated bene i 'ary i$ Name: twat 70 r) kuS Date of Birth: 62 ,6 S3 Sex MO Social Security Number: Phone Number: Address: 0. K0 Employee's Signature: Date: S/-,)- /// d STATE OF FLORIDA The forego.ng ins rument was ?knowledged befo e me this COUNTY OF PINELLAS S 311/0 by -1) U ?6- LA who is personally known to me or who has provided as iden ?di tic n oat Notary Public Ao (snature) I - i? ?J Name of Notary Printed My Commission expires: NOTARY PUBLIC-STATE OF FLOILA Deborah L. Fore Commission # DD763426 Rev. 4/08 Expires: MAY 15, 20!2 BONDED THRU ATLbNTIC BO?DLNG CO., LtiC, Form #9900-0009 File Name: Pension Entitlement Option Form Item # 3 ruidauneiii IIUIIIuei i Page 27 of 116 1F Estimated Pension Worksheet 11 Bruno Yankus LAST DATE PAID: 5/21/2010 BENEFITS DATE 7/15/1985 CREDITED SERVICE 24.8500 -{?-- Signature: Date: S -LQ l d GROSS CALENDAR PENSION YEAR EARNINGS 2004 $51,459.53 2006 $52,238.39 2007 $60,387.00 2008 $59,757.32 2009 $59,678.15 $283,520.39 (5 Year Total) 5/ $56,704.08 (Yearly Avg) 12/ $4,725.34 (Monthly Avg) x 0.0275 (Benefit Rate) x 24.8500 (Yrs of Service) $3,229.18 (Est Mtly Pension) Item # 3 HLCaU111T1e11L HUITIDer I Page 28 of 116 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors 10-May-10 sm ESTIMATE clract01 Version: Employee Name: Bruno Yankus 1-4-96 Employee Date of Birth: 10 16 1953 Marital Status: m Spouse Date of Birth: 2 16 1953 Beneficiary Date of Birth: 2 16 1953 Benefit Commencement Date : 6 1 2010 Estimated Monthly Normal Reti rement Benefit: $3,229.18 Actuarial Equivalent Adjustment Factors: Option 1 J&S Annuity 1.00000 Option 2 Life Annuity 1.08868 Option 3 10 Year Certain 1.06933 Option 4 50% J&S 1.03151 Option 5 75% J&S 1.00512 Option 6 100% J&S 0.98004 ESTIMATE Estimated Monthly Benefit $3,229.18 $3,515.56 $3,453.05 $3,330.93 $3,245.70 $3,164.73 Item # 3 Hnacnmem numoer i Page 29 of 116 CITY OF CLEAR'v"JA TER EMPL OYEES' SEPARA T/ON PA Y PREFERENCES PREFERENCE #1 Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. I, 'SL- PlM V- ?" an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # ( and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation v? sick floaters bonus hours Lump Sum vacation sick 6 *0 floaters bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. 1 EMPLOYEE'S SIGNATURE: SOCIAL SECURITY #: ADDRESS: 3 O U 6?? hgr, ??' WITNESSES: 7&S PHONE: -7 D -711f L1-)- -S-303 DATE: S /d Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 3 Hnacnmem numoer i Page 30 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM I, IIICi/1GtG I r-14- uvIV jir of Clearwater General Employees'' Pensi / Ian. Job Classifica n: (.' Em ' CkG / r 1 11? I' S T Department: V 1`L ' li-r Benefits Date: o o Date of Birth: 0 3 a Spouse's Name: Spouse's Date of Birth: do hereby apply for retirement under the City 6 r c c4_4 Sex: OM F -Division: Date of Hire: l0 d- g0 Resignation Date: 7 30j o Sex: M The type of pension for which I am applying is (check only one): Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #6) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 - Joint and Survivor Annuit; The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Annuity The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary's estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 50% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Item # 3 Attachment number 1 Page 31 of 116 .untion h - 1100% joint & Survivor Annuiiv -(must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 6) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) I understand that once my first pension check is received, my decision on this option is irrevocable. Option #: 1 1 Description: Joint and Survivor Annuity Employee's Signature: Date: Dependent children under the age of 18 and residing in my household are: Child's Name Sex Date of Birth If taking Option 2 sign below- -- Option #:.2 Description: Life Annuity Employee's Signature.- Date: Option #: S Description: D I`n4 V .VVl,V1 0j My desi ated beneficiary is: Name: sr ] e0`1'11-?'11 Date of Birth- J? 3C+ S? Sex MO Social Security Number: - Phone Number: "7A V le ((J-` S30 Address: 300 Employee's Signature: l??za hCz vgn 'DV . r Loa er 3 3 -7 4??l k ?S L_4?_ Date: STATE OF FLORIDA The forego' g in trument was a knowledged b ore me this / COUNTY OF PINELLAS S" J ?/ D by y? )!2_ ,ho is personally known to me or who has provided as id=2?=id Ptl oath Notary Public (Signature) ? - n -bi yAJU r /'l ??vnYl// Name of Notary Printed My Commission expires: tiOTARY PUBLIC-STATE OF FLORIDA Deborah L. Ford Commission # DD763426 Expires: IMAY 15, 2012 Rev. 4/08 BONDED THRU ATLIkYFIC BONDING CO., INC. Form #9900-0009 File Name: Pension Entitlement Option Form Item # 3 Hnacnmem numoer i Page 32 of 116 11 Estimated Pension Worksheet _ 11 Michael Harrington LAST DATE PAID: 5/31/2010 BENEFITS DATE 10/20/1980 CREDITED SERVICE 29.6139 Signature: ?-? Date: S 0 /c7 GROSS CALENDAR PENSION YEAR EARNINGS 2003 $51,903.39 2004 $55,302.87 2007 $57,122.17 2008 $66,708.26 2009 $64,370.43 $295,407.12 (5 Year Total) 5/ $59,081.42 (Yearly Avg) 12/ $4,92145 (Monthly Avg) x 0.0275 (Benefit Rate) x 29.6139 (Yrs of Service) $4,009.57 (Est Mtly Pension) Item # 3 Hnacnmem numoer i Page 33 of 116 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors 21-May-10 sm ESTIMATE c1ract01 Version: Employee Name: Michael Harrington 1-4-96 Employee Date of Birth: 10 23 19,52 Marital Status: m Spouse Date of Birth: 12 30 1958 Beneficiary Date of Birth: 12 30 1958 Benefit Commencement Date : 8 1 2010 Estimated Monthly Normal Retirement Benefit: $4,009.57 Estimated Monthly Actuarial Equivalent Adjustment Factors: Benefit Option 1 J&S Annuity 1.00000 $4,009.57 Option 2 Life Annuity 1.12196 $4,498.56 Option 3 10 Year Certain 1.09968 $4,409.26 Option 4 50% J&S 1.04249 $4,179.95 Option 5 75% J&S 1.00684 $4,037.00 Option 6 100% J&S 0.97354 $3,903.49 ESTIMATE Item # 3 Attachment number 1 Page 34 of 116 OF CLEARIVIVAT'ER EMPL O YEES' SEPARA T/ON PA Y PREFERENCES PREFERENCE #1 Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1/2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. l C? UN d O?4 1 C, , an employee of the City of Clearwater, pension benefits under the City's Employees' Pension Plan. hereby apply for I hereby certify that I ully understand the preferences offered to me. I choose to retire using separation pay preference # and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation sick floaters bonus hours Lump Sum q Ly- '7k vacation sick floaters /C 00-0 bonus hours I understand that my preference cannot be changed once this form is sand that my deci ion is irrevocable. EMPLOYEE'S SIGNATURE: , SOCIAL SECURITY #: WI NESSES: ADDRESS: PHONE: Revised 1/02 Form #9900-0008 Y-J l?'( bo = DA i t: File Name: Employee Separation Pay Pref Item # 3 Attachment number 1 Page 35 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM of Clearwater General Employees' Job Classification: Department: Benefits Date: _ Date of Birth: - Spouse's Name: Spouse's Date of Birth: ion Plan. do hereby apply for retirement under the City V IV IJ IVI I. _ Date of Hire: Resignation Date: / p Sex: M L./ The type of pension for which I am applying is (check only one): C? Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #6) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 - Joint and Survivor Annuity The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Ann uit; The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary's estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 50% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Item # 3 Attachment number 1 Page 36 of 116 k )IJ B - i iCi% joint & Survivor annuity -(must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 6) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) I understand that once my first pension check is received, my decision on this option is irrevocable. Option #: Employee's Signature: Date: Dependent children under the age of 18 and residing in my household are: Child's Name Sex Date of Birth If taking Option 2 sign below: Option #: 2 Description: Life Annuity Employee's Signature: Date: Option #: Description: >l n Mow: n l3 i Il ? . I CJ??i UG'f' 17nVP My designated benefi ary is: Name: L ArL- i e - Date of Birth: S? Sex N F Social Security Number: Address: Employee's Signature: _ Phone Number: Date: oZ( Q STATE OF FLORIDA The foreg ing i strument was ac nowledged betgre me tnls COUNTY OF PINELLAS Q by `c.;?r Y ?c- who is personally known to me or who has provided as iden ' ' ation and who /d'd t k n oat . Notary Public ,, / (Signatrre) ?l 0 Y U- ? ' Name of Notary Printed My Commission ex .re3?I nr;^ ' 7L C•A ."" Deborah L, Ford Gominlssion # DD763426 Expires: NIAY 15, 2012 Rev. 4/08 aoxDSe rxxyAT ?u rtc_ aprv[Ns e9,, rxG: Form #9900-0009 File Name: Pension Entitlement Option Form Description: mint and Survivor Annuity Item # 3 Attachment number 1 Page 37 of 116 Estimated Pension Worksheet David Doyle LAST DATE PAID: BENEFITS DATE CREDITED SERVICE Signature: Date: GROSS CALENDAR PENSION YEAR EARNINGS 5/31/2010 2002 $58,921.71 1/28/1985 2003 $59,964.14 25.3417 2004 $59,089.99 2007 $60,951.75 2008 $60,689.21 $299,616.80 (5 Year Total) 5/ $59,923.36 (Yearly Avg) 12/ $4,993.61 (Monthly Avg) x 0.0275 (Benefit Rate) x 25.3417 (Yrs of Service) $3,480.03 (Est Mtly Pension) Item # 3 - Attachment number 1 Page 38 of 116 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors 20-May-10 sm ESTIMATE clract01 Version: Employee Name: David Doyle 1-4-96 Employee Date of Birth: 11 10 1954 Marital Status: M Spouse Date of Birth: 1 28 1953 Beneficiary Date of Birth: 1 28 1953 Benefit Commencement Date : 6 1 2010 Estimated Monthly Normal Retirement Benefit: $3,480.03 Estimated Monthly Actuarial Equivalent Adjustment Factors: Benefit Option 1 J&S Annuity 1.00000 $3,480.03 Option 2 Life Annuity 1.08039 $3,759.79 Option 3 10 Year Certain 1.06313 $3,699.71 Option 4 50% J&S 1.02870 $3,579.92 Option 5 75% J&S 1.00467 $3,496.29 Option 6 100% J&S 0.98174 $3,416.48 ESTIMATE Item # 3 Attachment number 1 Page 39 of 116 C'TYOFC LEARVVATER EMPLOYEES' SEPARAT/ON PAY PREFERENCES PREFERENCE #1 Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. I, an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # i and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation sick floaters Lump Sum vacation sick floaters bonus hours Id 0, ® bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. EMPLOYEE'S SIGNATURE: SOCIAL SECURITY #: - w/ / WI NESSES: ADDRESS: 1 S G I Wr A /v--7 (;V 4a"-ad '33-7-70 IJ PHONE: DATE: Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 3 Attachment number 1 Page 40 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM 1, C C)f UU Ct #- 1 0/.-) by f/. of Clearwater General Employees' Pension Plan. Job Classification: Department: Benefits Date: 07 Date of Birth: 3 31 Spouse's Name: Spouse's Date of Birth: do hereby apply for retirement under the City IOnIc Sex: (@ F er.. Division: Date of Hire: `1 O Resignation Date: 5-1.2 b /O A Sex: M F The type of pension for which I am applying is (check only one): X Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #6) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 - Joint and Survivor Annuity The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Annuity The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary's estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 50% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75%, Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Item # 3 Attachment number 1 Page 41 of 116 Option b -100% joint & Survivor Annuijy - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 6) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) I understand that once my first pension check is received, my decision on this option is irrevocable. Option #: Employee's Signature: Date: Dependent children under the age of 18 and residing in my household are: Child's Name Sex Date of Birth If taking Option 2 sign below: Option #: 2 Description: Life Annuity Employee's Signature: Date: Option #: Description: My desi ated beneficiary is: I Name: C????r??0.-?L? N hu II Date of Birth: a ! q 3 _ Sex M Social Security Number: _ Phone Number: 17 dl (Y- V- -7 9 3 y Address: 377 Em Signature: r) S //&- / 0 STATE OF FLORIDA The foregoing i7110 trument was a k wledge before me 20// is COUNTY OF PINELLAS by who is personally known to me or who has provided as ident' ' atio and who did/did t e n oath. Notary Public ,,/,jgnat Name of Notary Printed My Commission expirpp -b I Al h OF FLORIDA Deborah L. Ford ord Commission #DD763426 Expires: MAY 15, 2012 Rev. 4/08 BONDED TIIRU ATI L11IC BONDING Co., INdC. Form #9900-0009 File Name: Pension Entitlement Option Form Description: Joint and Survivor Annuity Item # 3 Attachment number 1 Page 42 of 116 Estimated Pension Worksheet Ed Turnbull LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 5/20/2010 2/4/1980 30.2944 Signature: a4? vS11 T 6 GROSS CALENDAR PENSION YEAR EARNINGS 2004 $63,494.77 2006 $62,039.51 2007 $61,802.75 2008 $62,281.83 2009 $61,072.84 $310,691.70 (5 Year Total) 5/ $62,138.34 (Yearly Avg) 12/ $5,178.20 (Monthly Avg) x 0.0275 (Benefit Rate) x 30.2944 (Yrs of Service) $4,313.94 (Est Mtly Pension) Item # 3 HLCaU111T1e11L HUITIDer I Page 43 of 116 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors 18-May-10 sm ESTIMATE clract01 Version: Employee Name: Ed Turnbull 1-4-96 Employee Date of Birth: 3 31 1956 Marital Status: S Spouse Date of Birth: Beneficiary Date of Birth: 2 9 1939 Benefit Commencement Date : 6 1 2010 Estimated Monthly Normal Retirement Benefit: $4,313.94 Actuarial Equivalent Adjustment Factors: Option 1 J&S Annuity 1.00000 Option 2 Life Annuity 1.00000 Option 3 10 Year Certain 0.98696 Option 4 50% J&S 0.98424 Option 5 75% J&S 0.97655 Option 6 100% J&S 0.96897 ESTIMATE Estimated Monthly Benefit $4,313.94 $4,313.94 $4,257.69 $4,245.96 $4,212.77 $4,180.10 Item # 3 ruidauneiii iiuinDUI i Page 44 of 116 CITY OF CLEARVVA TER EMPL O PEES' SERA RA T/ON PA Y PREFERENCES PREFERENCE #I Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. 1 1 1oey\u S 1??1 G an employee of pension benefits under the City's Employees' Pension Plan. the City of Clearwater, hereby apply for I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation sick floaters bonus hours Lump Sum v2 vacation '7' 7 (0/sick floaters ?°2l?.. bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. W TNESSES: 4" 4?v_ Revised 1/02 Form ##9900-0008 EMPLOYEE'S SIGNATURE: SOCIAL SECURITY #: - j ADDRESS: (:?S_7 (? ?r ?? ?G S T O/eci rw a4e` FL -7( PHONE: '712 7/ 79"- S y21- DATE: Yll 7 // G) File Name: Employee Separation Pay Pref Item # 3 HLCaU111T1e11L HUITIDer I Page 45 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM 1, riuvrI of Clearwater General Employees' P ion Plan. do hereby apply for retirement under the City Job Classifica i?or): o s' c e Soh Sex f M) F Benefits Date: o2S C Date of Hire: S Date of Birth: p 7 Resignation Date JS 117 d Spouse's Name: , ?? lea I a? Sex: M 0 Spouse's Date of Birth: S3 The type of pension for which I am applying is (check only one): C Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #6) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 - Joint and Survivor Annuity The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Annuity The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary s estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 500/. point & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75%, Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Item # 3 Page 46 of 116 Option 6 - 1100% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 6) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) I understand that once my first pension check is received, my decision on this option is irrevocable. Option #: I Description: Joint and Survivor Annuity Employee's Signature: Date: Dependent children under the age of 18 and residing in my household are: Child's Name Sex Date of Birth If taking Option 2 sign below: Option #: 2- Description: Life Annuity Employee's Signature: Date: Option #: Description: My desig--na d bepefi a7 is: Name: l e r? 1 K a 1 cr Date of Birth Social Security Number: Address: Emoloyee's Signature: -7 / L e a /.,v 1 Sex '"'O Phone Number: 7a 7 Z7 17 -Sy74-- ? P / u n CrG S r , FC -3>3-7 6 % Date: - 1740 STATE OF FLORIDA The fore oing strument was acknowledged before me this COUNTY OF PINELLAS i s" 7 U by_? ??? ?'1"? t` i nf, who is personally known to me or who has provided as identif ZK?izi7- tae oath. Notary Public (Signature) - Cl O t_o_ - f t1i Name of Notary Printed My Commission expires: ,NOTARY PUBLIC-STATE OF FLORIDA Deborah L. Ford Commission # DD763426 Rev. a/O8 Expires: MAY 15, 2012 BONDED THRU ATLANTIC BONDING CO., DiC. Form #9900-0009 File Name: Pension Entitlement Option Form Item # 3 ruidauneiii IIUIIIuei i Page 47 of 116 II Estimated Pension Worksheet II Thomas King LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 5/31/2010 4/25/1980 30.1000 Signature: hd,4t,(? ? Date: / q // v GROSS CALENDAR PENSION YEAR EARNINGS 2004 $54,315.34 2006 $54,292.79 2007 $57,022.85 2008 $58,611.22 2009 $63,568.84 $287,811.04 (5 Year Total) 5/ $57,562.21 (Yearly Avg) 12/ $4,796.85 (Monthly Avg) x 0.0275 (Benefit Rate) x 30.1000 (Yrs of Service) $3,970.59 (Est Mtly Pension) Item # 3 Page 48 of 116 City of Clearwater Employees' Pension Plan Actuarial Equivalence Fa ctors 10-May-10 sm ESTIMATE clract01 Version: Employee Name: Thomas King 1-4-96 Employee Date of Birth: 5 27 1956 Marital Status: m Spouse Date of Birth: 6 8 1953 Beneficiary Date of Birth: 6 8 1953 Benefit Commencement Date : 6 1 2010 Estimated Monthly Normal Reti rement Benefit: $3,970.59 Estimated Monthly Actuarial Equivalent Adjustment Factors: Benefit Option 1 J&S Annuity 1.00000 $3,970.59 Option 2 Life Annuity 1.06612 $4,233.11 Option 3 10 Year Certain 1.05221 $4,177.91 Option 4 50% J&S 1.02381 $4,065.13 Option 5 75% J&S 1.00389 $3,986.04 Option 6 100% J&S 0.98473 $3,909.97 ESTIMATE Item # 3 Page 49 of 116 %JIf' T Y OF LOU' EAR'd'?A TER EMPL O PEES' SEPARA T/ON PA Y PREFERENCES PREFERENCE #1 Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. l v loev- nd e an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # i and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation sick floaters bonus hours Lump Sum 0&-39. vacation -7 & Y°'?3 sick ff U floaters /°20° 0 bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. -Z46? - EMPLOYEE'S SIGNATURE: J SOCIAL SECURITY #: WITNESSES: ADDRESS: ?UP?-C Ct S 41 PHONE: 7d -7/33/ -7 %4-3 DATE: S? Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 3 Page 50 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM I, DODKI r U--unQjt:?I of Clearwater General Employees' Pension Plan. do hereby apply for retirement under the City Job Classification: ce-? r)*C0n i C_ _.>J e r'J i SC/? Sex: ® F Department: d1% era pr• Division: Benefits Date: S 0 Date of Hire: Date of Birth: . Resignation Date: Spouse's Name: I SU I e Sex: M(9 Spouse's Date of Birth: 3 6 The type of pension for which I am applying is (check only one): Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #6) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 - Joint and Survivor Annuit; The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Annuity The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary's estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 50% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Item # 3 Page 51 of 116 Option 6 - 100% join' & ?rvivor annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 6) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) I understand that once my first pension check is received, my decision on this option is irrevocable. Option #: Employee's Signature: Description: Joint and Survivor Annuity Dependent children under the age of 18 and residing in my household are: Child's Name Sex Date: Date of Birth If taking Option 2 sign below: Option #: 2 Description: Life Annuity Employee's Signature: Date: Option #: Description: CYO Jt? ??" ?yaUO? rt n ?,, My desig ted benefice is: Name: ++SUP1 ??Cle?Date of Birth: L-) S/6U Sex Mo /-93 Social Security Number: 3 - Phone Number: 70?? 3 L j Address: 3 7 r C a A b' - i U'l ? L 3 L-/6 97Y Employee's Signature: s"/f 7// 0 STATE OF FLORIDA The foreg 7Ong i71-0 trument was acknowwledged before me this COUNTY OF PINELLAS S / 7 by NQ We-V 4- 0()e, who is personally known to me or who has provided as identifi on a d who did/d' notn at . Notary Public (Sign Lure) ? JC pr&, - t ?? Name of Notary Printed My Commission expires: NOTARY PUBLIC-STATE OF FLOM-: , Deborah L. Forte Commission # DD763426 Rev. aloe ` Eacnires: MAY 15, 2012 Form Pens #9900-0009 gprrpEnTHItUnT1r+N , e ,m i e me: Pension Entitlement Option Form Item # 3 ruidauneiii IIUIIIuei i Page 52 of 116 I( Estimated Pension Worksheet II Robert Gundel LAST DATE PAID: 5/31/2010 BENEFITS DATE 5/5/1980 CREDITED SERVICE 30.0722 l Signature: Date: S d y v GROSS CALENDAR PENSION YEAR EARNINGS 2005 $63,904.30 2006 $67,249.34 2007 $66,526.20 2008 $67,684.28 2009 $68,383.92 $333,748.04 (5 Year Total) 5/ $66,749.61 (Yearly Avg) 12/ $5,562.47 (Monthly Avg) x 0.0275 (Benefit Rate) x 30.0722 (Yrs of Service) $4,600.09 (Est Mtly Pension) Item # 3 Hnacnmem numoer i Page 53 of 116 City of Clearwater'' Employees' Pension Plan Actuarial Equivalence Factors 24-May-10 sm ESTIMATE clract01 Version: Employee Name: Robert Gundel 1-4-96 Employee Date of Birth: 12 3 1956 Marital Status: m Spouse Date of Birth: 3 21 1960 Beneficiary Date of Birth: 3 21 1960 Benefit Commencement Date : 6 1 2010 Estimated Monthly Normal Reti rement Benefit: $4,600.09 Estimated Monthly Actuarial Equivalent Adjustment Factors: Benefit Option 1 J&S Annuity 1.00000 $4,600.09 Option 2 Life Annuity 1.08331 $4,983.32 Option 3 10 Year Certain 1.07051 $4,924.42 Option 4 50% J&S 1.02970 $4,736.69 Option 5 75% J&S 1.00483 $4,622.31 Option 6 100% J&S 0.98114 $4,513.32 ESTIMATE Item # 3 HLCdGnfnenL nUfnUer I Page 54 of 116 CITY v^F CLEARVVA TER EMPL OYEES' SEPARA T/ON PA Y PREFERENCES PREFERENCE #1 Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. I, ?Cr' e- Si , an employee of pension benefits under the City's Employees' Pension Plan. the City of Clearwater, hereby apply for I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # - and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation sick floaters ` bonus hours Lump Sum v?flr vacation 68 sick Q floaters bonus hours I understand that my preference cannot be changed once this form is si ned and hat my decision is irrevocable. EMPLOYEE'S SIGNATURE: ocl 1A 0 SOCIAL SECURITY #: WITNESSES: ADDRESS: J Y ?4 do e C+JO0 v' ?r• 1 Pq VLjjQ k- PHONE: -7"2-7 /'_7 3Y-YN °LATE:d Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 3 HLCaU111T1e11L HUITIDer I Page 55 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM I Y do hereby apply for retirement under the City of Clearwater enerai Employes' Pension Plan. ?iv Job Classificatioja: .XJ` At E ra' r Sex: O F Department: k 7e5 Division: Benefits Date: l a a0 -7 Date of Hire:. 2= 1 a ? Date of Birth: 115A S?lf Resignation Date: 571.2 116 /)1 e0 01 Q / 0- C1?' Sex: M Spouse's Name: (D Spouse's Date of Birth: OL .)- 1,573 The type of pension for which I am applying is (check only one): Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #6) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 - Joint and Survivor Annuity The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Annuit The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary's estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 50% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Option 5 - 750/. Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Item # 3 --ui-I II IIUIi I-I i Page 56 of 116 Option 6 - 100% joint & S?rvivor AnnaiiT - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 6) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) I understand that once my first pension check is received, my decision on this option is irrevocable. Option #: 2 Des ription: Joint and Survivor Annuity A/ ejaaAA Employee's Signature: Dependent children under the age of 18 and rest ing in my household are: Child's Name Sex Date: Date of Birth If taking Option 2 sign below: Option #: 2 Description: Life Annuity Employee's Signature: Date: If takina Option 3.4. 5. or 6 fill in beneficiarv information and sian below: Option #: Description: My designated beneficiary is: Name: Date of Birth: Sex M F Social Security Number: Phone Number: Address: Employee's Signature: Date: STATE OF FLORIDA The foregoi 79 ins rument was ack owledged be re me this COUNTY OF PINELLAS /2'f /O by CI- ff-d 0(f who is 0 11 personally known to me or who has provided as identif tion d who did/ no a?Z f Notary Public p (Sign ure) Name of Notary Printed My Commission expires: :i, T PUBLIC-STATE F FLORIDA. Deborah L. Ford ' Commission # DD763426 .` Expires: MAY 15, 2012 Rev. 4/08 ii,,:ii)F D THRU ATU.,-rIC BONDING CO., INC. Form #9900-0009 File Name: Pension Entitlement Option Form Item # 3 Hnacnmem numoer i Page 57 of 116 11 Estimated Pension Worksheet Roger Hooey LAST DATE PAID: 5/21/2010 BENEFITS DATE 12/20/1979 CREDITED SERVICE 30.4194 Signature: &14-44? 4UL Date: o GROSS CALENDAR PENSION YEAR EARNINGS 2005 $56,968.97 2006 $63,497.30 2007 $70,134.27 2008 $68,943.68 2009 $68,813.79 $328,358.01 (5 Year Total) 5/ $65,671.60 (Yearly Avg) 12/ $5,472.63 (Monthly Avg) x 0.0275 (Benefit Rate) x 30.4194 (Yrs of Service) $4,578.05 (Est Mtly Pension) Item # 3 Attachment number 1 Page 58 of 116 EMPL O YEES' SEPARA T/ON PA Y PREFERENCES PREFERENCE #1 Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. e r 0tin C,t-u h , an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation sick floaters bonus hours Lump Sum d y?" y vacation sick S?l ? floaters ?`12 - S bonus hours C;TY OF CLEARI?ATER I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. EMPLOYEE'S SIGNATURE: SOCIAL SECURITY #: - , W TNESSES: y &44ta.L )?- 4tia? ADDRESS: G cA,! e,04- 1-6 117 t-- Revised 1/02 Form #9900-0008 Ju?ec?ri; FC, 3 y?cm?- PHONE: 7?7 (7 3 y- s°Z?? DATE: S/°ZU /l y File Name: Employee Separation Pay Pref Item # 3 Attachment number 1 Page 59 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM I, Ny lgert- Va v) 9 U_,_4 V) to. do hereby apply for retirement under the City of Clearwater General Employees' Pension Plan. Jps1 qtn ? ! o 0-4001 lJC? TlcG/n Sex: F Job Classification: io Department: ,n -e Division: Benefits Date: `r ?d Date of Hire: Y / id Date of Birth: S y Resignation Date: (o Ik /O Spouse's Name: PA_ Sex: M F Spouse's Date of Birth: The type of pension for which 1 am applying is (check only one): Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #6) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 - Joint and Survivor Annuity The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option - Life Ann city The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] Option 3 - 10 Year Certain & Life Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary s estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 500/. Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Item # 3 Page 60 of 116 Option 6 - 1100% joint F. Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 6) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) I understand that once my first pension check is received, my decision on this option is irrevocable. Option #: 1 Description: Joint and Survivor Annuity Employee's Signature: Date: a U ?? Dependent children under the age of 18 and residing in my household are: Child's Name Sex Date of Birth If taking Option 2 sign below: Option #: 2 Description: Life Annuity Employee's Signature: Date: If takinq Option 3, 4, 5, or 6 fill in beneficiarv information and sian below: Option #: Description: My designated beneficiary is: Name: Date of Birth: Sex M F Social Security Number: Phone Number: Address: Employee's Signature: Date: STATE OF FLORIDA The 7ring trument was ackn/'owledged before this COUNTY OF PINELLAS ?U ? t-f he_ who is by g0 `j ei-I (1G h De personally known to me or who has provided as identizu= /did no tae oat (Signatue) / Notary Public d Y?? "- Name of Notary Printed My Commission expires Deborah L. Ford Commission # DD763426 Expires: MAY 15, 2012 BGNDED THRU A`1`LAYTIC BoNDLNG CO., INC. Rev. 4/08 Form #9900-0009 File Name: Pension Entitlement Option Form Item # 3 HLCaU111T1e11L HUITIDer I Page 61 of 116 II Estimated Pension Worksheet II Robert Van Duyne LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 5/31/2010 4/14/1980 30.1306 Signature: Date: S o vd GROSS CALENDAR PENSION YEAR EARNINGS 2005 $45,098.30 2006 $48,931.27 2007 $49,516.76 2008 $48,581.94 2009 $49,944.87 $242,073.14 (5 Year Total) 5/ $48,414.63 (Yearly Avg) 12/ $4,034.55 (Monthly Avg) x 0.0275 (Benefit Rate) x 30.1306 (Yrs of Service) $3,342.99 (Est Mtly Pension) Item # 3 ruidauneiii IIUIIIDUI i Page 62 of 116 C11 Y v^F CLEARIvATER EMPL O PEES' SEPARA T/ON PA Y PREFERENCES PREFERENCE #1 Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. I, , CkV-N COCh (?,?1; an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation sick floaters bonus hours Lump Sum Oc? a vacation 1(9 5' (P I sick floaters 00" 6 bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. EMPLOYEE'S SIGNATURE: SOCIAL SECURITY #: - WN SES: QADDRESS: PHONE: Revised 1/02 Form #9900-0008 ATE: File Name: Employee Separation Pay Pref Item # 3 -Attac men num er Page 63 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM 1 ' ?r' Lt Vl v ' ?C.hGt v /t do hereby apply for retirement under the City of Clearwater General Employees' ension Plan. Job Classification: ?° ?? ?? :?Y? ?n Un C? 0-r7 S ?? F QrU' ?0YSex: Department: a [,?c Division: Benefits Date: -2 / 30 7? Date of Mire: ? 3 7 Date of Birth: Resignation Date: '7 3 o O Spouse's Name: ?-endc"_ klc U!94 /i P, Sex: M® Spouse's Date of Birth: _/b 3i b d The `type of pension for which I am applying is (check only one): ?L Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #6) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 - Joint and Survivor Annuity The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Annuity The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary's estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 50%, Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Item # 3 Attachment num e?? 1- Page 64 of 116 Option 6 - 11010% joint & -Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 6) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) I understand that once my first pension check is received, my decision on this option is irrevocable. Option #: 1 Employee's Signature: Description: _Joint and Survivor Annuity Dependent children under the age of 18 and residing in my household are: Child's Name Sex Date: Date of Birth If taking Option 2 sign below: Option #: 2 Description: Life Annuity Employee's Signature: Date: If takinq Option 3, 4, 5, or 6 fill in beneficiary information and sian below: Option Description: l "?U '75-15)"14- 't- 3brV I'?od Ain V, My des' ated ene . Name: _0Ke,1cACL XcLay is,y: ., ti/; Date of Birth: G 31 ro0 Sex M( Social Security Number: _ Phone Number: - - Address: Employee's Signature: a ate: d STATE OF FLORIDA The fore g ing in trument was cknowledged before me this COUNTY OF PINELLAS / (? by -, '0,,' d1lCIC, L,*k/? who is personally known to me or who has provided as ide i Icatio and who di?f /did' no a oath. K Notary Public (Signature) din Name of Notary Printed My Commission eXAr.Ros; ZiOZ `Si AFlW :sandx2[ NOTARY PTTSLTC-STATE OF FLORIDA 9Zf£9LQQ#aotsstuicn03 ""'•o Deborah L, Ford FJ03 'Z gaaop(I Commission # DD763426 Rev. 4/08 HCI WIA go a1V11S-aI'lsf1 d A LO U = -•' Expires: MAY 15, 2012 Form #9900-0009 File Nsme9ensioni_-An Hemenf6p28nbrm Item # 3 -A1fac men number Page 65 of 116 IL_ Estimated Pension Worksheet II Brian McLaughlin LAST DATE PAID: 7/30/2010 BENEFITS DATE 7/30/1977 CREDITED SERVICE 33.0000 Signature: &"_,d V"- Date:--!;-& GROSS CALENDAR PENSION YEAR EARNINGS 2004 $53,328.08 2006 $52,017.88 2007 $53,224.59 2008 $54,290.23 2009 $55,057.38 $267,918.16 (5 Year Total) 5/ $53,583.63 (Yearly Avg) 12/ $4,465.30 (Monthly Avg) x 0.0275 (Benefit Rate) x 33.0000 (Yrs of Service) $4,052.26 (Est Mtly Pension) Item # 3 ac men num er Page 66 of 116 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors 24-May-10 sm ESTIMATE clract01 Version: Employee Name: Brian McLaughlin 1-4-96 Employee Date of Birth: 11 5 1948 Marital Status: m Spouse Date of Birth: 10 31 1960 Beneficiary Date of Birth: 10 31 1960 Benefit Commencement Date : 8 1 2010 Estimated Monthly Normal Reti rement Benefit: $4,052.26 Actuarial Equivalent Adjustment Factors: Option 1 J&S Annuity 1.00000 Option 2 Life Annuity 1.18894 Option 3 10 Year Certain 1.15104 Option 4 50% J&S 1.06337 Option 5 75% J&S 1.01003 Option 6 100% J&S 0.96179 ESTIMATE Estimated Monthly Benefit $4,052.26 $4,817.89 $4,664.30 $4,309.05 $4,092.91 $3,897.42 Item # 3 Attachment number 1 Page 67 of 116 CiT Y OFCLEARvvATER EMPL O YEES' SEPA RA T/ON PA Y PREFERENCES PREFERENCE #1 Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. r? eoatl CO' - an employee of pension benefits under the City's Employees' Pension Plan. the City of Clearwater, hereby apply for I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation sick floaters bonus hours Lump Sum 1as? ?? vacation yX1- /q.sick floaters bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. EMPLOYEE'S SIGNATURE: SOCIAL SECURITY #: 1 WIZNESSES: DDRESS: - l/ffii YY , , PHONE. _ DATE: Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 3 Attachment number 1 Page 68 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM I, Caro Coo jDe r of Clearwater General Emolov s' Pension Plan. Job Classification: Department: C Benefits Date: S 7; Date of Birth: b it t5l Spouse's Name: Spouse's Date of Birth: do hereby apply for retirement under the City ?r y CC -eck ?'1 tC1Ic-n Sex: M 0 Division: Date of Hire: Resignation Date: 7 3U /o !v Sex: M F The type of pension for which I am applying is (check only one): y\ Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #6) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 - Joint and Survivor Annuity r The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Annuity The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary's estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 50% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Item # 3 Attachment number T Page 69 of 116 Option 6 - 100% Joint & S irvivor Ann ?-y - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)} I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 6) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) I understand that once my first pension check is received, my decision on this option is irrevocable. Option #: 1 Descriptio .Joint and Survivor Annuity Employee's Signature: *!? Date: 0 Dependent children under the age of 18 and residing in my household are: Child's Name Sex Date of Birth If taking Option 2 sign below: Option #: -2- Description: Life Annuity Employee's Signature: Date: If takina Option 3.4.5, or 6 fill in beneficiary information and sian below: Option #: Description: My designated beneficiary is: Name: Date of Birth: Sex M F Social Security Number: Phone Number: Address: Employee's Signature: Date: STATE OF FLORIDA The fore oing i strument was ack wledged b fore me this COUNTY OF PINELLAS / ?q ?6 by ? rc- Ud Ci who is personally known to me or who has provided as identific ' n a d who didbdid of k oath , Notary Public 4?tau ??J\ L Name of Notary Printed My Commission expires: n NOTARY Deborah L. Fore hng commission # DD763425 .;?. Expires: MAY 15,20!2 Rev. 4/08 BO ED Txxu nTt v?Tlc BON ntxc Form #9900-0009 File Name: Pension Entitlement Option Form Item # 3 Attachment number 1 Page 70 of 116 Estimated Pension Worksheet Cara Cooper LAST DATE PAID: 6/30/2010 BENEFITS DATE 5/2/1978 CREDITED SERVICE 32.1611 Signature:, 4j"JL f X?4- Date: 511911o GROSS CALENDAR PENSION YEAR EARNINGS 2005 $41,031.78 2006 $42,417.69 2007 $44,439.27 2008 $45,956.52 2009 $47,740.95 $221,586.21 (5 Year Total) 5/ $44,317.24 (Yearly Avg) 12/ $3,693.10 (Monthly Avg) x 0.0275 (Benefit Rate) x 32.1611 (Yrs of Service) $3,26,6.29 (Est Mtly Pension) Item # 3 Attachment number 1 Page 71 of 116 'I OF CLEAR r"?A TER EMPL O YEES' SEPA RA T/ON PA Y PREFERENCES PREFERENCE #1 Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. I 1 Ct e C?L? UCH YJ-r an employee of the City of Clearwater, pension benefits under the City's Employees' Pension Plan. hereby apply for I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation sick floaters bonus hours Lump Sum vacation I Ct q' 3-2sick 502 -floaters bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. EMPLOYEE'S SIGNATURE: SOCIAL SECURITY #: WITNESSES: ADDRESS: , 96a Revised 1/02 Form #/9900-0008 PHONE: r )ATE: S cf d File Name: Employee Separation Pay Pref Item # 3 Attachment number 1 Page 72 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM 1, " f y ) of- e_- t6_ Loo j29- r' of Clearwater General Employees' ension Plan. Job Classification: Department: Benefits Date: _ Date of Birth: do hereby apply for retirement under the City VIVIJIVI I. - Date of Hire: Resignation Date: Spouse's Name: /y,4 Sex: M F Spouse's Date of Birth: The type of pension for which I am applying is (check only one): Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #6) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 - Joint and Survivor Annuity The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Annuity The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary s estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 50% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Item # 3 Attachment number 1 Page 73 of 116 Option 6 - 1100% Joint F4 Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 6) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) I understand that once my first pension check is received, my decision on this option is irrevocable. Option #: 2 Description: Joint and Survivor Annuity I Employee's Signature: Date: -? Id- Dependent children under the age of 18 and residing in my household are: Child's Name Sex Date of Birth If taking Option 2 sign below: Option #: 2 Description: Life Annuity Employee's Signature: Date: If takina Option 3. 4. 5, or 6 fill in beneficiarv information and siqn below: Option #: Description: My designated beneficiary is: Name: Date of Birth: Sex M F Social Security Number: Phone Number: Address: Employee's Signature: Date: STATE OF FLORIDA The foreg ing i trument was a knowledge bef e me this COUNTY OF PINELLAS , o by ?, I 0100J-17el- ---who is S personally known to me or who has provided as ide&= i7/o 4,t an th. Notary Public (Signature' f? Y_t;?/L, Name of Notary Printed My Commission expires: Rev. 4/08 Form #9900-0009 NOTARY PUBLIC-STATE OF FLORIDA Deborah L. Ford Commission #DD763426 Expires: MAY 15, 2012 P,ONDED THRU ATL ALN F[C BONDING CO., INC. File Name: Pension Entitlement Option Form Item # 3 Attachment num er Page 74 of 116 it Estimated Pension Worksheet II Marietta Cooper LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 6/30/2010 10/21/1974 35.6917 Signature: ?Date: S t 9 1 (.) GROSS CALENDAR PENSION YEAR EARNINGS 2005 $47,316.41 2006 $49,083.03 2007 $50,176.20 2008 $51,599.45 2009 $53,239.77 $251,414.86 (5 Year Total) 5/ $50,282.97 (Yearly Avg) 12/ $4,190.25 (Monthly Avg) x 0.0275 (Benefit Rate) x 35.6917 (Yrs of Service) $4,112.82 (Est Mtly Pension) Item # 3 Attachment number 1 Page 75 of 116 CITY OF CLEARWA TER EMPL OYEES' SEPARA TION PA Y PREFERENCES PREFERENCE #1 Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. I, an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation sick floaters bonus hours Lump Sum I J' Id-vacation 6 G U, /gsick ?Sfloaters ` bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. EMPLOYEE'S SIGNATURE: SOCIAL SECURITY #: WITNESSES: ADDRESS: q6 - PHONE: 7 2 , 7?DATE: S-/`'-oho Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 3 Attachment num er Page 76 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM of Clearwater General Employees' Pe(ision Plan. do hereby apply for retirement under the City Job Classification: A(' C 0 vyi •1 ?f J-) `1 i C 1 Ctt*-) Sex: Department: +"a 1-'4 _j Division: Benefits Date: 5 14 S ?' Date of Hire: Date of Birth:. ?T -7 S [Resignation Date: 3 U / U Spouse's Name. ?j '- 04 ` Sex: M F Spouse's Date of Birth: The type of pension for which I am applying is (check only one): Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #6) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 - Joint and Survivor Annuity r The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Annuity The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary's estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 50% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Item # 3 Attachment number 1 Page 77 of 116 Option b - 100% joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 6) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) I understand that once my first pension check is received, my decision on this option is irrevocable. Option #: 1 Employee's Signature: Description: Joint and Survivor Annuity Dependent children under the age of 18 and residing in my household are: Child's Name Sex Date: Date of Birth If taking Option 2 sign below: Option #: -?- Description: _ Life Annuity Employee's Signature: Date: Option #: Description: .SG My designated benefi ary is' Name: ?4 t? ?? }r y Date of Birth: Social Security Number Address: C i Emplovee's Sianature: W Date: S of U / / U STATE OF FLORIDA The foregoi g instrument was acknowledged befo me this COUNTY OF PINELLAS S v>U A) by t_? C,yC 5 - G''t?F , who is personally known to me or who has provided as identif' tion nd who di did?k a ath. n Notary Public ?j ?, (Signature)) _ J I X170 ??? ?1 / u r ??' Name of Notary Printed My Commission expires: Rev. 4/08 Form #9900-0009 `t- Cvrv., ?o>/ /q f7P7W L/ Sex IQ F 4 Phone Number: 7 /_7 3 y` ®,f le NOTARY PUBLIC-STATE OF FLORIDA Deborah L. Ford Commission # DD763426 Expires: MAY 15, 2012 4GONDEv THRG ATLAN^t'tc ao;,nt:tfde,tr2ne Pension Entitlement Option Form Item # 3 HLCaU111T1e11L HUITIDer I Page 78 of 116 Estimated Pension Worksheet Theresa Coffey LAST DATE PAID: 5/28/2010 BENEFITS DATE 5/5/1980 CREDITED SERVICE 30.0639 Signature: Y-OL.(-J- . -&I" 5bo 0 Date: GROSS CALENDAR PENSION YEAR EARNINGS 2005 $36,251.02 2006 $38,967.57 2007 $39,621.25 2008 $40,048.68 2009 $41,172.24 $196,060.76 (5 Year Total) 5/ $39,212.15 (Yearly Avg) 12/ $3,267.68 (Monthly Avg) x 0.0275 (Benefit Rate) x 30.0639 (Yrs of Service) $2,701.58 (Est Mtly Pension) Item # 3 Page 79 of 116 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors ESTIMATE Employee Name: Employee Date of Birth: Marital Status: Spouse Date of Birth: Beneficiary Date of Birth: Benefit Commencement Date Theresa Coffey 7 7 1955 M 4 14 1954 4 14 1954 6 1 2010 20-May-10 sm clract01 Version: 1-4-96 Estimated Monthly Normal Retirement Benefit: $2,701.58 Actuarial Equivalent Adjustment Factors: Option 1 J&S Annuity 1.00000 Option 2 Life Annuity 1.07671 Option 3 10 Year Certain 1.06119 Option 4 50% J&S 1.02745 Option 5 75% J&S 1.00447 Option 6 100% J&S 0.98250 ESTIMATE Estimated Monthly Benefit $2,701.58 $2,908.83 $2,866.88 $2,775.74 $2,713.66 $2,654.30 Item # 3 Page 80 of 116 C% T Y OF CLEARvvA T ER EMPL OYEES' SEPARA T/ON PA Y PREFERENCES PREFERENCE #1 Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. nn -_- I, M ) n a - teys+a- an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation L 5"() sick floaters bonus hours Lump Sum vacation ??a ?'3sick floaters bonus hours I understand that my preference cannot be changed once this form is si ned and that decision is irrevocable. _ r EMPLOYEE'S SIGNATURE: X--' SOCIAL SECURITY #: " ' - WI NESSES: ADDRESS: - - PHONE: ' - UHF-: S&///10 Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 3 ruidauneiii IIUIIIDUI i Page 81 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM 1, VI, of Clearwater Job Classification: Department: Benefits Date: _ Date of Birth: Spouse's Name: Spouse's Date of Birth: rS0/)K) 0- do hereby apply for retirement under the City )n Plan. 7_(?CAg/"G/;5?0 Sex: M FO Division: Date of Hire: `r' 1 d'Q Resignation Date: 3a / D ? O S4--a- Sex: (9 F The type of pension for which I am applying is (check only one): Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #6) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 - Joint and Survivor Annuity The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Annuity The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary's estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 50% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% Joint F. Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Item # 3 eral Employees' Pen Page 82 of 116 Option 6 - 100 % joint is ?gur, 1V0r anniiit.• -(must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] 1 have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 6) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) I understand that once my first pension check is received, my decision on this option is irrevocable. Option #: 1 Description: Joint and Survivor Annuity Employee's Signature: Date: Dependent children under the age of 18 and residing in my household are: Child's Name Sex Date of Birth If taking Option 2 sign below: Option #: _.Z_ Description: Life Annuity Employee's Signature: Date: If taking Option 3, 4, 5 or 6 fill in beneficiary information and sign below: Option Description: `'?o J o: n? S r vCJr? ,+? v?hu ?'1?c? My desig ted benef iary is: Name: a "-f d3 err- Date of Birth: Se) F c? Social Security Number: Phone Number: 7 Address: _ Employee's Signature: ^ r Date: 4,)_ 1 STATE OF FLORIDA The foregoi g instrument was knowledged beforeye?thJi? COUNTY OF PINELLAS j ?O by Oj /- Co J'7Y? who is personally known to me or who has provided as identi ' atio and who di /di n tae oat Notary Public Q I-( gnature)L r - vJ F^??/"_J jam'/[`) Name of Notary Printed My Commission expires: INOTARY PUBLIC-STATE OF FLORID Deborah L. Ford :Commission # DD763426 Rev. 4/08 Lxpires: MAY 15, 2012 ,oNDZD THRU VrLkN 1C BONDING CO., INC. Form #9900-0009 File Name: Pension Entitlement Option Form Item # 3 Page 83 of 116 L Estimated Pension Worksheet Virginia Costa LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 9/30/2010 9/29/1980 30.0028 Signature: 0-4- , k=?, -S --C! (3 Date: GROSS CALENDAR PENSION YEAR EARNINGS 2005 $37,703.84 2006 $39,337.91 2007 $41,509.52 2008 $41,869.05 2009 $43,043.82 $203,464.14 (5 Year Total) 5/ $40,692.83 (Yearly Avg) 12/ $3,391.07 (Monthly Avg) x 0.0275 (Benefit Rate) x 30.0028 (Yrs of Service) $2,797.89 (Est Mtly Pension) Item # 3 Empp- ruidauneiii IIUIIIuei i Page 84 of 116 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors 20-May-10 sm ESTIMATE clract01 Version: Employee Name: Virginia Costa 1-4-96 Employee Date of Birth: 6 28 1956 Marital Status: m Spouse Date of Birth: 6 28 1954 Beneficiary Date of Birth: 6 28 1954 Benefit Commencement Date : 10 1 2010 Estimated Monthly Normal Reti rement Benefit: $2,797.89 Estimated Monthly Actuarial Equivalent Adjustment Factors: Benefit Option 1 J&S Annuity 1.00000 $2,797.89 Option 2 Life Annuity 1.06964 $2,992.73 Option 3 10 Year Certain 1.05569 $2,953.71 Option 4 50% J&S 1.02503 $2,867.91 Option 5 75% J&S 1.00409 $2,809.32 Option 6 100% J&S 0.98398 $2,753.08 ESTIMATE Item # 3 Page 85 of 116 CO'Y v^F CLEARVVA TER EMPL O YEES' SEPARA T/ON PA Y PREFERENCES PREFERENCE #1 Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. 1, ?-w2r, ?(a vi an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation sick floaters bonus hours Lump Summa vacation sick ' floaters bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. EMPLOYEE'S SIGNATURE: _k Lmn SOCIAL SECURITY #: WITNESSES: `ADDRESS: 11, 4a4c4?1 - P HONE: Revised 1/02 Form #9900-0008 )a- S? - 7 9 O DATE: S? 7 ?0 File Name: Employee Separation Pay Pref Item # 3 Page 86 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM V, - of Clearwater General Employees' Pension Plan. Job Classification: Department: Benefits Date: _ Date of Birth: do hereby apply for retirement under the City Division: Date of Hire: Resignation Date: Spouse's Name: Sex: M F Spouse's Date of Birth: The type of pension for which I am applying is (check only one): X Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #6) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 -Joint and Survivor Annuity The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Annuitt The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary's estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 50% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Item # 3 Page 87 of 116 Option 6 - i00% loin' & S t Div or Ann tits - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 6) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) I understand that once my first pension check is received, my decision on this option is irrevocable. Option #: 1 Employee's Signature: Description: -J-o:mt and Survivor Annuity Date: -7 ho Dependent children under the age of 18 and residing in my household are: Child's Name Sex Date of Birth If taking Option 2 sign below: Option #: 2 Description: Life Annuity Employee's Signature: Date: If taking Option 3, 4, 5, or 6 fill in beneficiary information and sign below: Option #: Description: My designated beneficiary is: Name: Date of Birth: Sex M F Social Security Number: Phone Number: Address: Employee's Signature: Date: STATE OF FLORIDA The fore o. g in rument was acknowled?d before me y COUNTY OF PINELLAS S I (?. by ,,, (,r who is personally known to me or who has provided as identffitcatio and who did/did no a lie g6m oath /??) css m?e> ! Notary Public ??JCJf - ?? • Name of Notary Printed ORIDA NOTARY PUBLIC-STATE OF FL My Commission expires; neborah L. Ford Commission # DD7634 6 Expires: MAY 15, 2012 BONDED TxRU ATLA ,-nC BONDING CO., INC. Rev. 4/08 Form #9900-0009 File Name: Pension Entitlement Option Form Item # 3 Page 88 of 116 11 Estimated Pension Worksheet - ! Gwen Hollander LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 6/4/2010 8/12/1999 10.8111 Signature: Date: 10 GROSS CALENDAR PENSION YEAR EARNINGS 2005 $37,672.74 2006 $39,163.19 2007 $40,729.68 2008 $42,344.87 2009 $43,785.73 $203,696.21 (5 Year Total) 5/ $40,739.24 (Yearly Avg) 12/ $3,394.94 (Monthly Avg) x 0.0275 (Benefit Rate) x 10.8111 (Yrs of Service) $1,009.33 (Est Mtly Pension) Item # 3 Page 89 of 116 CfT Y OF `LEAR WA -TER EMPL OYEES' SEPARA T/ON PA Y PREFERENCES PREFERENCE #1 Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. I, ?? ?"!'? 0 iD?'?1 S d N an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # r and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation sick floaters bonus hours Lump Sum a vacation ?9 sick floaters bonus hours I understand that my preference cannot be changed once this form i signed and tha ecision is irrevocable. EMPLOYEE'S SIGNATURE SOCIAL SECURITY #: WITNESSES: Revised 1/02 Form #9900-0008 ADDRESS: AYE (2c't?1f C{, J PHONE: -7d'7 /74 C L-7 -7 / 71 DATE: I A ? O File Name: Employee Separation Pay Pref Item # 3 Page 90 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM of Clearwater General Employees' Pension Plan. Job Classification: Department: Benefits Date: Date of Birth: do hereby apply for retirement under the City Division: Date of Hire: Resignation Date: Spouse's Name: Sex: M F Spouse's Date of Birth: The type of pension for which I am applying is (check only one): Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #6) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 -Joint and Survivor AnnuitTr The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Annuity r The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary's estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 50% Joint & S irvivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% loin & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Item # 3 HLLa(;nf ne Page 91 of 116 Option 6 - 1100% joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 6) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) I understand that once my first pension check is received, my decision on this option is irrevocable. Option #: 1 Employee's Signatu Descrip r Date: 41 uepenaent children under the age of 18 and residing in my household are: Child's Name Sex Date of Birth If taking Option 2 sign below: Option #: 2 Description: _Life Annuity Employee's Signature: Date: If takinq Option 3, 4, 5, or 6 fill in beneficiary information and sian below: Option #: Description: My designated beneficiary is: Name: Date of Birth: Sex M F Social Security Number: Phone Number: Address: Employee's Signature: Date: STATE OF FLORIDA The foreg)ng insZ Q trument was acknowled ed before , e Is COUNTY OF PINELLAS L? c ! i , by ,? -Ca 2 e !71 CG' 1 '7Sa?J who is personally known to me or who has provided as identi c tion d who di did of e n ath. Notary Public ( ignature Name of Notary Printed Rev. 4/08 Form #9900-0009 My Commission expires: DA Deborah L. Ford Commission # DD763426 Expires: MAY 15, 2012 BONDED THRU ATLA,'4TIC BONDING CO., L'IC. File Name: Pension Entitlement Option Form Item # 3 Page 92 of 116 1- Estimated Pension Worksheet 11 Elizabeth Robinson LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 5/31/2010 12/23/1996 13.4389 Signature: 49? ` Date: S O GROSS CALENDAR PENSION YEAR EARNINGS 2005 $24,464.18 2006 $25,904.47 2007 $27,150.00 2008 $28,234.78 2009 $29,048.39 $134,801.82 (5 Year Total) 5/ $26,960.36 (Yearly Avg) 12/ $2,246.70 (Monthly Avg) x 0.0275 (Benefit Rate) x 13.4389 (Yrs of Service) $830.31 (Est Mtly Pension) Item # 3 Attachment number Page 93 of 116 CITY OF CLEARWATER EMPL O YEES' SEPARA TION PA Y PREFERENCES PREFERENCE #1 Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. I, ' I `y C ems' an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation _ sick floaters bonus hours Lump Sum ?'? vacation's+e- sick floaters bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. EMPLOYEE'S SIGNATURE: SOCIAL SECURITY #: WI NESSES: ADDRESS: C.?ar-den 1 - a ?° ??w ?d?t ? ?? 3 ass PHONE: -7 of- 7 l Y 3 °Z- y? ?I DATE: a I Revised 1/02 Form #19900-0008 File Name: Employee Separation Pay Pref Item # 3 Page 94 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM 1, t, v e r - do hereby apply for retirement under the City of Clearwater Ge eral Employees' Pension Plan. ?- I Job Classificati°z.? ` r 0. PS p. 1( k f11, Sex: G F Department: l? et v c1,?1 Division: Benefits Date: 10 IV Date of Hire: -7 _ Date of Birth: // Resignation Date: odU /Q Spouse's Name: ?i [Y,dy--- y / c- Vie c u e,, Sex: M F? Spouse's Date of Birth: / S v The type of pension for which l am applying is (check only one): X- Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #6) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 - Joint and Survivor Annuity The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Annuity The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] Option 3 - 10 Year Certain & Life AnnuiW - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary's estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 50% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75%, Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] Item # 3 ac Page 95 of 116 Option 6 - 100% -joint A Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. [Section 2.398 (b) (2) (a) (3)] I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 6) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) I understand that once my first pension check is received, my decision on this option is irrevocable. Option #: 1 \Description: _Joint and Survivor Annuity Employee's Signature: Date: Dependent children under the age of 18 and residing in my household are: Child's Name Sex Date of Birth If taking Option 2 sign below: Option #: 2 Description: Life Annuity Employee's Signature: Date: If taking Option3, 4, 5, or 6 fill in beneficiarv information and sian below: Option #: Description: My designated beneficiary is: Name: Date of Birth: Sex M F Social Security Number: Phone Number: Address: Employee's Signature: Date: STATE OF FLORIDA The foreg ing ins ument was acknowledq ed, b ye me this 4 ? COUNTY OF PINELLAS U p by t'11 ] + 1C who is personally known to me or who has provided as ide ti catio an who d' /dice n to e oath. Notary Public \ (sure) r J Name of Notary Printed My Commission ffinXFPVU4QG STAVE e Deborah L. Ford Commission # DD763426 Expires: MAY 15, 2012 AGYllED TIiRU ATLAS fIC GOADING'C Rev. 4/08 IlVC. Form #9900-0009 File Name: Pension Entitlement Option Form Item # 3 C2 Co `-f `? 31 Attacnment num er Page 96 of 116 11 Estimated Pension Worksheet it Billy McKeever LAST DATE PAID: 5/31/2010 BENEFITS DATE 10/17/1994 CREDITED SERVICE 15.6222 Signature: Date: -S GROSS CALENDAR PENSION YEAR EARNINGS 2004 $31,549.27 2005 $32,062.13 2006 $34,016.94 2008 $35,680.53 2009 $36,960.02 $170,268.89 (5 Year Total) 5/ $34,053.78 (Yearly Avg) 12/ $2,837.82 (Monthly Avg) x 0.0275 (Benefit Rate) x 15.6222 (Yrs of Service) $1,219.16 (Est Mtly Pension) Item # 3 ac Page 97 of 116 C1T Y OF CLEARLVATER EMPL OYEES' SEPARA T10N PA Y PREFERENCES PREFERENCE #1 Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. I, , Y? v C 4 an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # - and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation sick floaters bonus hours Lump Sum vacation sick floaters bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. EMPLOYEE'S SIGNATURE: - A- ?- ??- SOCIAL SECURITY #: - WITNESSES: ADDRESS: 41-01 i? V - 44 ,.I _- _ - PHONE: Revised 1/02 Form #9900-0008 TE: File Name: Employee Separation Pay Pref Item # 3 Attachment nuMDer "I Page 98 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM SWORN POLICE AND FIRE PERSONNEL 1, _U W of Clearwater Gen Job Classification: Department: Benefits Date: _ Date of Birth: Employees' L2a4--o V1 ids Plan. 4'er do hereby apply for retirement under the City Sex: n F Spouse's Name: Spouse's Date of Birth: Division: Date of Hire: I of3 i Resignation Date: , o / 0 6. Sex: M F Theype of pension for which I am applying is (check only one): Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension Early Retirement The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #7) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 - Joint and Survivor Annuity The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five-year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount, except that, if greater for police officers and firefighters, the normal form of benefit shall be an annuity paid monthly for the life of the participant with 120 payments guaranteed. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Annuity r The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary's estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 50% joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. The beneficiary can b j chaingpg at any time. [Section 2.398 (b) (2) (a) (3)] Attachment num er Page 99 of 116 Option 6 - 100% Joint & Survivor Annuity, - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)J Option 7 - 66 213% Joint P. Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 66 2/3% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)) I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 7) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) 1 understand that once my first pension check is received, my decision on this option is irrevocable. Option #: I Employee's Signature: Description: Joint and Survivor Annuity Dependent children under the age of 18 and residing in my household are: Child's Name Sex Date: Date of Birth If taking Option 2 sign below. Option #:. 2_ Description: Life Annuity Employee's Signature: Date: Option #: tv Description: / YJ °U ?0 0 it Usi? i ?` e ! yJ h c.+` 1L(, My desig ted ben ?iciary is' \./ Name: f v A " ?-'? Date of Birth: S 169 Sex MCF) 1 61 Social Security Number:. Phone lumber: - Address: - - - Employee's Signature: Date: 5 1-Clh _0 STATE OF FLORIDA The foregoi gin trum ant was alnowledged before. me this / COUNTY OF PINELLAS 5?/ 0 by ,J t fow h' AW-4?t hrvho is LJ C/ personally known to me or who has provided as identification and who did/did not take an oath. Notary Public ? ature)? xv Name of Notary Printed NOTARY PUMT My Commission expires: R}?Ui jiP s25 Rev. 4/08 ;... Form #9900-0053 File Name: Pension Entitlement Option Form 09% #Fle Page 100 of 116 IIEstimated Pension Worksheet -1I Dwayne Vaughan LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 5/1/2010 1/10/1983 27.3083 Signature: Date: I, rI GROSS CALENDAR PENSION YEAR EARNINGS 2005 $86,355.31 2004 $76,092.73 2007 $74,902.63 2008 $72,589.39 2006 $67,926.63 $377,866.69 (5 Year Total) 5/ $75,573.34 (Yearly Avg) 12/ $6,297.78 (Monthly Avg) x 0.0275 (Benefit Rate) x 27.3083 (Yrs of Service) $4,729.50 (Est Mtly Pension) Item # 3 ac men Page 101 of 116 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors Police and Fire Members Only 19-May-10 sm clract03 Version: August 9, 2000 Employee Name: Dwayne Vaughan Employee Date of Birth: 2 11 1959 Marital Status: m Spouse Date of Birth: 5 9 1966 Beneficiary Date of Birth: 5 9 1966 Benefit Commencement Date : 6 1 2010 Estimated Monthly Normal Retirement Benefit: $4,729.50 Estimated ...................... ................. Monthly Actuarial Equivalent Adjustment Factors: Benefit Normal Form 1.00000 $4,729.50 Life Annuity 1.08875 $5,149.23 10 Year Certain 1.07815 $5,099.13 50% J&S 1.03269 $4,884.11 67% J&S 1.01527 $4,801.70 75% J&S 1.00677 $4,761.54 100% J&S 0.98212 $4,644.96 Item # 3 Page 102 of 116 C/T Y OF CLEARA1ATER EMPL OYEES' SEPARA T/ON PA Y PREFERENCES PREFERENCE #1 Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. I. Lltl -?4e-' +-- , an employee of the City of Clearwater, hereby apply for Ij 1i pension benefits under the City's Employees' Pension Plan. I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation sick floaters bonus hours Lump Sum 99 Uvacation 6 y7 e sick 3,10 floaters bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. EMPLOYEE'S SIGNATURE: SOCIAL SECURITY #: WNESSES: ADDRESS: - ?n Revised 1/02 Form #19900-0008 PHONE: S1171/D File Name: Employee Separation Pay Pref Item # 3 Attachment number 1 Page 103 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM SWORN POLICE AND FIRE PERSONNEL of Clearwater G nployees' Pension Plan. do hereby apply for retirement under the City Job Classification Department: Benefits Date: _ Date of Birth: Spouse's Name: Spouse's Date of Birth: Sex: G F %- Division: '9 Date of Hire: l 3 O Resignation Date: 4- C3L& /G udi W1 S7- war-f' Sex: M 1 0 The type of pension for which I am applying is (check only one): _X? Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension Early Retirement The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #7) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 - Joint and Survivor Annuity The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five-year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount, except that, if greater for police officers and firefighters, the normal form of benefit shall be an annuity paid monthly for the life of the participant with 120 payments guaranteed. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Annuity The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary's estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 50% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] Item # 3 Attachment number Page 104 of 116 Option 6 - 100% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] Option 7 - 66 213% Joint & Survivor Annuity -(must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 66 2/3% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 7) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) I understand that once my first pension check is received, my decision on this option is irrevocable. Option #: 1 Employee's Signature: Date: Dependent children under the age of 18 and residing in my household are: Child's Name Sex Date of Birth If taking Option 2 sign below: Option #: -2- Description: Life Annuity Employee's Signature: Date: Option #: 1? Description: 10 0 cyc) -?_Td f ?,- *. 3'VYJ? ?ot/ My desigriate , b neficiary is: Name: V u i M 2C .:)C r- '" Date of Birth: 1-1 3C) ?U Sex Mo Social Security Number: Phone Number: Address: Description: Joint and Survivor Annuity re: /lam Date: S// 7// 0 STATE OF FLORIDA The fore qin ij?strument was a nowledged be e me this COUNTY OF PINELLAS / / by ec (7v?1 1-C CA/ 4P' who is personally known to me or who has provided as id ifica ' n and w did/mot an th. ?1- Notary Public (Signatt re) d ire Name of Notary Printed My Commission expires: NOTMy PUBLICM, CFFTOPTrh Jug - Comm bOi nh L, Ib ?. # DD7634 • Expires: 25 Rev. 4/08 Bt1NDEDTfII2IIATLell?'[q MAY 25, 2012 Form #9900-0053 File Name: Pension t iS6iq,OWion FormIke% # Fae Attachment number 1 Page 105 of 116 Estimated Pension Worksheet Gregory Stewart LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 5/31/2010 11/3/1989 20.5778 Signature: Date: ?L GROSS CALENDAR PENSION YEAR EARNINGS 2004 $71,033.07 2006 $75,653.88 2007 $80,596.29 2008 $85,013.01 2009 $86,869.96 $399,166.21 (5 Year Total) 5/ $79,833.24 (Yearly Avg) 12/ $6,652.77 (Monthly Avg) x 0.0275 (Benefit Rate) x 20.5778 (Yrs of Service) $3,764.73 (Est Mtly Pension) Item # 3 Attachmen number Page 106 of 116 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors Police and Fire Members Only 10-May-10 sm clract03 Version: August 9, 2000 Employee Name: Gregory Stewart Employee Date of Birth: 1 12 1950 Marital Status: m Spouse Date of Birth: 12 30 1950 Beneficiary Date of Birth: 12 30 1950 Benefit Commencement Date : 6 1 2010 Estimated Monthly Normal Retirement Benefit: $3,764.73 Estimated ...................... ................. Monthly Actuarial Equivalent Adjustment Factors: Benefit J&S Annuity 1.00000 $3,764.73 Life Annuity 1.11414 $4,194.42 10 Year Certain 1.08627 $4,089.52 50% J&S 1.04366 $3,929.09 67% J&S 1.02211 $3,847.96 75% J&S 1.01166 $3,808.63 100% J&S 0.98157 $3,695.34 Item # 3 Attachment num er Page 107 of 116 sf CITY OF CLEAR'Y?%ATER EMPL OYEES' SERA RA T/ON PA Y PREFERENCES PREFERENCE #9 Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. Y-e- el I, C / an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation sick floaters bonus hours Lump Sum o • o vacation sick 34'() floaters bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. EMPLOYEE'S SIGNATURE: SOCIAL SECURITY #: ?? ?- - WIT ESSES: ADDRESS: PHONE: /10 Revised 1/02 Form #19900-0008 File Name: Employee Separation Pay Pref Item # 3 Attachment number 1 Page 108 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM SWORN POLICE AND FIRE PERSONNEL I, itYcl7clr- nt of Clearwater General Employees' Job Classification: Department: Benefits Date: _ /1 Date of Birth: to Spouse's Name: Spouse's Date of Birth: i}on Plan./? ? IICC_ V Q(- C_eV, do hereby apply for retirement under the City Sex:( F ce Division: Date of Hire: % 3 1 y Res nation Date: f o _Ij e Y) IV) ?? Ul Sex: '"'?J Thertype of pension for which I am applying is (check only one): ?? Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension Early Retirement The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #7) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 - Joint and Survivor Annijity The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five-year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount, except that, if greater for police officers and firefighters, the normal form of benefit shall be an annuity paid monthly for the life of the participant with 120 payments guaranteed. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Annuity The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] option 3 - 10 Year Certain & Life AnnuiW - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary's estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 50% Joint & Survivor Annuft - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% Joint & Survivor Annu4 - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] Item # 3 ruidauneiii IIUIIIDUI i Page 109 of 116 Option 6 - JQQ% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] Option 7 - ss 2/3% joint & Survivor Annidtr - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 66 2/3% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 7) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) I understand that once my first pension check is received, my decision on this option is irrevocable. Option #: 1 Employee's Signature: The foregoin instrument wa?knowledged wore / me this 7/1?2L/CS by /ere-7 CC- e/1?,, who is personally known to me or who has provided as identifi anion acid who d1d/did o dl tab an oath. Dependent children under the age of 18 and residing in my household are: Child's Name Sex V U L=a Notary Public If takin Option 2 sign below: Option #: :)Description: Employee's Signature: Date: Option #: Description: Gt`i? `? C1 0 i' ?- U??? / 1-7 (1,y My designs ed be facia / J Name: rr 2 to of Birth: 1(%'J l? Sex M 4e N Social Security Number: Address: Em l z`" Date: 0 STATE OF FLORIDA COUNTY OF PINELLAS RECEIVED MAY 2 6 2010 H. R. DEPT Rev. 4/08 Form #9900-0053 Description: Joint and Survivor Annuity o? -- Date: Date of Birth Name of Notary Printed My Commission expires. _ -`- ',, 1> r r .;.. . ?' A i Item # 3 File Name: Pension Entitlement Option Form Police & Fire HLCaU111T1e11L HUITIDer I Page 110 of 116 Estimated Pension Worksheet Terence Kelly GROSS CALENDAR PENSION YEAR EARNINGS LAST DATE PAID: 5/20/2010 2004 $60,255.37 BENEFITS DATE 11/3/1989 2006 $62,888.33 CREDITED SERVICE 20.5472 2007 $79,902.69 2008 $77,049.61 2009 $81,961.31 $362,057.31 (5 Year Total) 5/ $72,411.46 (Yearly Avg) 12/ $6,034.29 (Monthly Avg) x 0.0275 (Benefit Rate) x 20.5472 (Yrs of Service) $3,409.67 (Est Mtly Pension) Prepared by: Deborah Ford Date: May 17, 2010 Item # 3 Attachment number 1 Page 111 of 116 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors Police and Fire Members Only 24-May-10 sm clract03 Version: August 9, 2000 Employee Name: Terence Kelly Employee Date of Birth: 10 25 1964 Marital Status: m Spouse Date of Birth: 11 24 1972 Beneficiary Date of Birth: 11 24 1972 Benefit Commencement Date : 6 1 2010 Estimated Monthly Normal Retirement Benefit: $3,409.67 Estimated ...................... ................. Monthly Actuarial Equivalent Adjustment Factors: Benefit J&S Annuity 1.00000 $3,409.67 Life Annuity 1.06890 $3,644.61 10 Year Certain 1.06275 $3,623.62 50% J&S 1.02540 $3,496.28 67% J&S 1.01168 $3,449.49 75% J&S 1.00495 $3,426.56 100% J&S 0.98530 $3,359.55 Item # 3 Attachment number Page 112 of 116 C/TY OFCLEARVVATER EMPL O YEES' SEPARA T/ON PA Y PREFERENCES PREFERENCE #1 Employees can receive a lump sum payment for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave at the time of separation from the City. There will be no 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 month. PREFERENCE #2 Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days (if applicable), and 1 /2 of accrued sick leave. Employee may choose to run out this time in any manner. Balance will be paid in a lump sum on employee's final paycheck. Termination date will be the final day of extended time. Pension benefits will begin the following month. ?G O -S V VL an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out Lump Sum . vacation sick 1, If -vacation ' FIJI sick floaters bonus hours floaters bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. EMPLOYEE'S SIGNATURE: SOCIAL SECURITY #: W TNESSES: ADDRESS: PHONE: Revised 1/02 Form #9900-0008 ^,.TE: S; Z6 / /-/ O File Name: Employee Separation Pay Pref Item # 3 MLL Page 113 of 116 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM SWORN POLICE AND FIRE PERSONNEL 1, J co7T r,E'Oh of Clearwater General Employees' Pension Plan. Job Classification: /I / ce Q Department: o "C e Benefits Date: 90 Date of Birth: it / / S76 Division: Date of Hire: f 0 Resignation Date: a '1 Spouse's Name: J+ l 1 l )CkAA1 ? Uh Sex: M F Spouse's Date of Birth: a 9 -7. The type of pension for which I am applying is (check only one): Regular Pension based on years of service Job-connected Disability Pension Non-job-connected Disability Pension Early Retirement The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The other optional forms (#2 - #7) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 -Joint and Survivor Annuity r The normal form of retirement benefit shall be an annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five years following the death of the Participant to the beneficiary, provided that following such five-year period the survivor annuity shall be reduced to 50% of the original survivor annuity amount, except that, if greater for police officers and firefighters, the normal form of benefit shall be an annuity paid monthly for the life of the participant with 120 payments guaranteed. [See section 2.397 (a) (3) (A)] The Participant's surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Annuity t The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease. [Section 2.398 (b) (2) (a) (1)] - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary. If payments to the beneficiary commence and he/she dies before the total of 120 payments has been made, the remainder of the payments is paid to the beneficiary's estate. If the first beneficiary predeceases the participant, he/she may designate a new beneficiary. If no beneficiary is alive at the time of the participant's death, the participant's estate will be paid the balance of the 120 payments. [Section 2.398 (b) (2) (a) (2)] Option 4 - 50% Joint F. Survivor Anni tyv, - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease- The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75%, Join & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. The beneficiary can bjtn#ej at any time. [Section 2.398 (b) (2) (a) (3)] do hereby apply for retirement under the City Sex: AM F ac men n Page 114 of 116 Option 6 - 100% Joint & Survivor Ann. pity - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] Option 7 - 66 213% Joint & Survivor Annui- (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives 66 2/3% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his/her pension and upon his/her death, benefits cease. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various alternative optional benefit payment methods (Options 2 through 7) under such Plan and have elected to receive my retirement benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.) 1 understand that once my first pension check is received, my decision on this option is irrevocable. Option #: I Employee's Signature: Dependent children under the age of 18 and residing in my household are: Child's Name Sex Date: Date of Birth If taking Option 2 sign below: Option #: _2_. Description: Life Annuity Employee's Signature: Date: If takina Option 3. 4. 5. 6, or 7 fill in beneficiary information and_sian below: Option #: f19 Description: 16-V cy 77 OJ -7 i" 1L J Ut Us yoi- , Vn17U14 My designs ed benef iary is: SJ Name: ?l i It -Pa,w oh . Date of Birth: // 02 y % Sex Mo Social Security Number: - hone Number: Address: V ? - Employee's Signature: Date: STATE OF FLORIDA COUNTY OF PINELLAS Description: Joint and Survivor Annuity The fore oin instrument was a no?yedged fore me this 02 ! g byco -TI S O f'? who is 16 personally known to me or who has provided as rol Rev. 4/08 Form #9900-0053 My Comm,issiop-6kj? rbs Notary Public Name of Notary Printed File Name: Pension Entitlement Option FormIPZSa ?re ruidauneiii IIUIIIuei i Page 115 of 116 II Estimated Pension Worksheet II Scott Dawson LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 9/24/2010 9/24/1990 20.0000 Signature: Date: j-C 8 GROSS CALENDAR PENSION YEAR EARNINGS 2005 $66,563.70 2006 $68,179.83 2007 $72,628.72 2008 $77,851.20 2009 $79,673.89 $364,897.34 (5 Year Total) 5/ $72,979.47 (Yearly Avg) 12/ $6,081.62 (Monthly Avg) x 0.0275 (Benefit Rate) x 20.0000 (Yrs of Service) $3,344.89 (Est Mtly Pension) Item # 3 ruidauneiii IIUIIIuei i Page 116 of 116 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors Police and Fire Members Only 20-May-10 sm clract03 Version: August 9, 2000 Employee Name: Scott Dawson Employee Date of Birth: 11 15 1963 Marital Status: m Spouse Date of Birth: 11 29 1967 Beneficiary Date of Birth: 11 29 1967 Benefit Commencement Date : 10 1 2010 Estimated Monthly Normal Retirement Benefit: $3,344.89 Estimated ...................... ................. Monthly Actuarial Equivalent Adjustment Factors: Benefit Normal Form 1.00000 $3,344.89 Life Annuity 1.06438 $3,560.24 10 Year Certain 1.05752 $3,537.28 50% J&S 1.02394 $3,424.98 67% J&S 1.01114 $3,382.14 75% J&S 1.00485 $3,361.13 100% J&S 0.98646 $3,299.62 Item # 3 Meeting Date:7/13/2010 Pension Trustees Agenda Council Chambers - City Hall SUBJECT / RECOMMENDATION: Approve Vested Pension as Submitted by Employee SUMMARY: Thomas Coyle, Police Officer, Police Department, was employed by the City on December 20, 1999, and began participating in the Pension Plan on that date. Mr. Coyle terminated from City employment on May 21, 2010. The Employees' Pension Plan provides that should an employee cease to be an employee of the City of Clearwater or change status from full-time to part-time after completing ten or more years of creditable service (pension participation), such employee shall acquire a vested interest in the retirement benefits. Vested pension payments commence on the first of the month following the month in which the employee normally would have been eligible for retirement. Section 2.393 (p) provides for normal retirement eligibility when a participant has completed twenty years of credited service in a type of employment described as "hazardous duty" and further specifically defines service as a Police Officer as meeting the hazardous duty criteria. Mr. Coyle would have completed 20 years of service on December 20, 2019. His pension will be effective January 1, 2020. Review Approval: 1) Clerk Cover Memo Item # 4 Hnacnmem numoer i Page 1 of 1 APPLICATION FOR VESTED RIGHTS PENSION ' r 1 o VhC45 `- C41 t . beina a person leavina eMDlovment with the City of Clearwater, Florida, and having completed ten (10) or more years of credited service, uch service having occurred during the period from (date of entry into Pension Plan) `? ?` u 111 9. to (date of resignation or change of status) f? d d 0 0 hereby makes application to receive the vested rights pension provided or by the City Code of Ordinances. As such former employee, I understand the pension requested will be computed pursuant to the provisions of the City Code of Ordinance in effect on the date of resignation. I hereby further certify that my date of birth is y 0 yiuCk r? I ?7, I _7 The date I will begin to receive my pension will be cl?ck nuq V, 1A Joao Further, I additionally certify that I have made no application seeking to obtain a return of the contributions that I paid into the Pension Fund during the period of my employment set forth above, I have not been convicted of a felony during my period of employment, and I have not recpived any other type of pension from the City. Signature Social Security Number a 1t Ce- _ Department/Division Street Addre Job Classification City, State, Zip Code STATE OF FLORIDA The foregoing instrument was acknowledged before COUNTY OF PINELLAS me this r day of kn Y ? l , 20 10 by ( 0?'nGS ec, who is personally know to me or who has provided T-L by"\'ty '_S L C"trISt as identification and who did/did not take an oath. 4Notary Public ? Jd ra !j L - ho, Name of Notary Printed NOTa^Y PUBLIC-STATE OF FLORIDA My commission expires:: Deborah L. Ford com. i Exuires: MAY 15, 2012 CQN RD THRB hnI'wnc So,=NO Co., INC. Rev. 4/09 Vested l eension 5 4 orrm Meeting Date:7/13/2010 Pension Trustees Agenda Council Chambers - City Hall SUBJECT / RECOMMENDATION: Approve changing the performance measurement benchmark for ING Investment Management Co. (ING IM) from the Standard and Poors 500 Index to the Russell 1000 Growth Index and authorize the appropriate officials to execute same. SUMMARY: ING IM (formerly Aetna Capital Management) was one of the first two domestic equity managers hired by the pension plan. The benchmark chosen at the time was the Standard and Poors 500 Index, which was one of the few indexes available. The Standard and Poors 500 is composed of many of the largest companies listed on the New York and NASDAQ stock exchanges and includes both growth and value stocks. Since hiring ING IM, the pension plan has diversified by adding additional managers representing various investment styles. ING IM occupies the space in the portfolio for the large market capitalization (large cap) growth manager. Staff has been working to update the various benchmarks and recommends that the more appropriate benchmark for ING IM, as a large cap growth manager, would be the Russell 1000 Growth Index. This index measures the performance of the large-cap growth segment of the U.S. equity universe. It includes those Russell 1000 large-cap companies with higher price-to-book ratios and higher forecasted growth values. The Pension Investment Committee concurs that the Russell 1000 Growth Index would provide a better measure of ING Investment Management's performance as a large cap growth manager. The pension plan's attorney has approved the agreement amendment per the attachment. Type: Current Year Budget?: Other None Budget Adjustment: None Budget Adjustment Comments: Current Year Cost: Not to Exceed: For Fiscal Year: Annual Operating Cost: Total Cost: to Review 1) Financial Services 2) Office of Management and Budget 3) Clerk 4) Assistant City Manager 5) Clerk 6) City Approval: Manager 7) Clerk Cover Memo Item # 5 Attachment number 1 Page 1 of 1 ING '' INVESTMENT MANAGEMENT June 22, 2010 The City of Clearwater Employees' Pension Fund (the "Client') wishes to change the benchmark referenced in the letter agreement (the "Agreement") dated June 23, 1982, as amended from time to time, by and between the Client and ING Investment Management Co. ("ING IM", formerly known as Aetna Capital Management, Inc.). Effective , 2010* the new benchmark for the Client's Large Cap Growth portfolio managed by the ING IM will be the Russell 1000 Growth Index. As such, all references to the S&P 500 Index shall be changed to the Russell 1000 Growth Index, wherever such benchmark is referenced in the Agreement, including the Statement of Investment Objectives and Guidelines. *Please sped effective date on or after June 30, 2010 ING Investment Management Co. By: Name: Eileen Madden Title: Senior Vice President Countersigned: City of Clearwater, Florida By: Name: William B. Horne II Title: City Manager Approved as to form: Attest: Assistant City Attorney Cynthia E. Goudeau City Clerk Item # 5