Loading...
08/16/2010 4 PENSION TRUSTEES AGENDA Location: Council Chambers - City Hall Date: 8/16/2010- 9:00 AM 1. Call to Order 2. Approval of Minutes 2.1 Approve the minutes of the July 13, 2010 Pension Trustees Meeting as submitted in written summation by the City Clerk. Attachments 3. Pension Trustee Items 3.1 Approve the sub-advisory relationship between Wentworth, Hauser and Violich, Inc. and Hirayama Investments and authorize appropriate officials to execute same. Attachments 3.2 Approve hiring MEPT as a core real estate manager for the Employees Pension Plan, authorize a contract with New Tower Trust as the trustee and authorize the appropriate officials to execute same. Attachments 3.3 Accept new hires into Pension Plan. Attachments 3.4 Approve employee requests for regular pensions. Attachments 4. Other Business 5. Adjourn Meeting Date: 8/16/2010 Pension Trustees Agenda Council Chambers - City Hall SUBJECT / RECOMMENDATION: Approve the minutes of the July 13, 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 9 COMMUNITY REDEVELOPMENT AGENCY MEETING MINUTES CITY OF CLEARWATER July 13, 2010 Present: Trustee/Chair 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 - CRA Executive Director/Assistant City Manager, Pamela K. Akin - City Attorney, Cynthia E. Goudeau - City Clerk, and Rosemarie Call - Management Analyst. To provide continuity for research, items are in agenda order although not necessarily discussed in that order. 1. Call to Order - Trustee/Chair Frank Hibbard The meeting was called to order at 9:08 a.m. at City Hall. 2. Approval of Minutes 2.1 Approve the minutes of the Jun 14, 2010 etin s submitted in written summation by the City Clerk. Trustee Bill Jonson moved to approve the minutes of the June 14, 2010 CRA Meeting as submitted in written summation by the City Clerk. The motion was duly seconded and carried unanimously. 3. CRA Items 3.1 oorov the Assin nt and Assu otion of v loo nt Aar nt from CRA 2010-07-13 Item #11 Attachment number 1 Page 2 of 9 15557, Page 1062 of the Public Records of Pinellas County, Florida (the "Records") (collectively, the "Development Agreement"). On October 16, 2009, Waters Edge One, L.L.C., a Delaware limited liability company ("Prior Owner") conveyed all of its right, title and interest in the Project, including all remaining unsold condominium units in the Project, to Assignee by that certain Special Warranty Deed (the "Deed") recorded in Official Records Book 16729, Page 2018 of the Records. The Prior Owner assigned its rights under the Development Agreement to Assignor, by Assignment and Assumption of Development Agreement recorded March 29, 2010 in Official Records Book 16869, Page 1459 of the Records. In connection with that certain Contract of Purchase and Sale, bearing an effective date of March 12, 2010 between Assignor and Assignee, Assignor is conveying rights under the Development Agreement to Assignee. Consent to the assignment by the Community Redevelopment Agency is required. Community Redevelopment Agency staff recommends the Board consent to the assignment. Trustee John Doran moved to approve the Assignment and Assumption of Development Agreement from Water's Edge Clearwater, LLC to Water's Edge Real Estate Acquisition, L.P. and authorize the appropriate officials to execute the Consent to Assignment. The motion was duly seconded and carried unanimously. The CRA staff objectives are to 1) support existing retail business viability in a period of economic downturn by creating larger crowds to create dining and retail demand for businesses in the Cleveland Street District; and, 2) provide our retail recruitment efforts with a better customer base to encourage new retailers/restaurateurs with the confidence to locate in the Cleveland Street District during the current economic downturn; 3) "expose" additional potential restaurant/retail customers and investors to the Cleveland Street District through CRA 2010-07-13 Item #21 Attachment number 1 Page 3 of 9 attendance at District events. With the state of the economy and the status of the new residential buildings in downtown, the two major "attractors" to accomplish the CRA objectives delineated above are: 1) the Capitol Theatre and 2) the 4th Friday events. The Capitol Theatre is expanding program offerings and, the CRA staff and the 4th Friday volunteer group wish to see an increased frequency and quality of the 4th Friday events to create 10 "signature" events (similar in "draw" to the Miracle on Cleveland Street at Christmas). 4th Friday has proposed a business concept to "ramp up " their program operations, with a companion financing plan based upon, in part, CRA "seed money" during the first 1 or 2 years of the process, while private funding sources are identified and developed. The intent is that the private contributions replace CRA "seed" money. CRA funds would allow the group to enhance the program for the 2010-2011 fiscal year, while fund raising and partnerships are pursued. The 4th Friday volunteer group has agreed to create a Not-for-Profit organization, to be known as Downtown Events, Inc., to receive and manage the funds and the program. The proper documentation showing the formation of a Not-for-Profit has not been received from the State and approval of this item is contingent upon receiving that documentation. The Memorandum of Agreement memorializes the discussions and provides for a $75,000 "seed money" appropriation from the CRA Redevelopment Fund to partially fund the $250,000 business plan. The DDB will be asked to provide $50,000 and the remaining $100,000 will be provided from private fund raising efforts. In response to questions, CRA Executive Director Rod Irwin said the principals in the group are those involved in the volunteer effort. The group does not have enough time for fundraising and launch first event in September. The number of outdoor events will evolve as weather permits. It was stated that the $75,000 is from Tax Increment Funds dedicated to Downtown, not the General Fund. In response to a concern, Economic Development and Housing Director Geri Campos Lopez said the Downtown Development Board (DDB) has budgeted $50,000 for the 4th Friday events. It was suggested that the $75,000 seed money be contingent on receiving the DDB funds. CRA 2010-07-13 Item #31 Attachment number 1 Page 4 of 9 Trustee Bill Jonson moved to approve a Memorandum of Agreement between the CRA and Clearwater Downtown Events, Inc., for the provision of an Expanded and Enhanced schedule of 4th Friday events in the Cleveland Street District, contingent on receiving $50,000 from the Downtown Development Board, approve a $75,000 seed money grant to Clearwater Downtown Events, Inc. to underwrite a portion of the expanded 4th Friday Program, and authorize the appropriate official to execute the Agreement. The motion was duly seconded and carried unanimously. The new website will support the overall strategy for downtown revitalization, which is to create a destination. The objectives for developing a website focused on the Cleveland Street District include: 1) to continue to build brand identity, awareness and interest in the Cleveland Street District; 2) provide a user-friendly tool for persons to access information on retail, commercial, restaurant, event and parking in the District. The website marketing strategy will be fully developed during the discovery phase of this engagement, but will inevitably feature heavy marketing to local and regional markets through multiple media sources; "cross pollination" of the web address on partner media vehicles(i.e. REH web site, Jazz holiday promotions); and, perhaps most importantly, inclusion of the website connectivity in tourist marketing efforts to expose the District and the resources/events to visitors to the County and our beaches. The tracking/analytics feature of the site will allow for continuous monitoring and adjustment of site marketing. Specifically, the RFP calls for the development of a stand-alone site that is dynamic, extremely easy to navigate, visually pleasing, safe and secure, quick to load and operate, interactive and informational for the citizens of and visitors to the Cleveland Street District in downtown Clearwater, as well as property and business (current and potential) owners. In addition, the "stand alone" nature of the website is intended to allow the CRA maximum entrepreneurial opportunity for marketing and event promotion, joint ventures with District businesses and stakeholder groups (i.e. video promotion of 4th Friday events); marketing promotion of joint-venture projects in the District(i.e.Water's Edge), as well as e-commerce opportunities in the future . CRA 2010-07-13 Item #41 Attachment number 1 Page 5 of 9 Enhanced capabilities and features will include: 1) Multimedia content accommodation (i.e. MP3 or Flash) with imbedded capability to upload audio/video for display; 2) E-mail newsletter functionality to accommodate tools such as Constant Contact for group messaging and marketing; 3) Site optimization for mobile phone compatibility; 4) Easy to use calendar feature for events posting; 5) Tracking/analytics feature for marketing and quality control: 6) Interactive maps for directions and business, parking and event location; 7) Intuitive, easy-to-use content management system(CMS) to allow CRA non- technical staff to manage, edit and update site; 8) Easily retrievable Cleveland Street District Business Directory. Future site enhancements anticipate a "self update" capability whereby businesses, restaurants and community calendar users will be able to input and modify their site information directly, subject only to "gatekeeper" review by the Downtown Manager or other appropriate CRA staff. The RFP was advertised on the City's website, in local newspapers and through electronic mailing to select marketing and public relation firms. Twenty-one (21) firms from across the nation submitted proposals in response to the RFP. On May 4, 2010, the selection committee met to evaluate the written proposals and identify finalists who most closely met the objectives of the CRA for Website Development for the Cleveland Street District as delineated in the RFP. The Interview/Selection Committee consisted of: Rod Irwin, CRA Executive Director; Dan Mayer, Information Technology Director; Courtney Orr, Downtown Manager; Stu Sjouwerman, President, Sunbelt Software. The Selection Committee identified six proposals that appeared to best meet the selection criteria based upon a rating formula in the RFP. The selection criteria used was as follows: Expertise in website design (30%) CRA 2010-07-13 Item #5I Attachment number 1 Page 6 of 9 Qualifications of firm and key personnel (20%) Previous performance and experience with similar projects/references (20%) Technical approach to project (20%) Cost quoted (10%) The top six firms were invited to make formal, detailed, in-person presentations to the selection committee on May 18 and 19. The six short-listed firms were: Artemis Solutions Group; East Lansing, MI Bayshore Solutions; Tampa, FL Blenderbox, Brooklyn, NY Chappel Roberts; Tampa, FL FSC Marketing Communications; Pittsburgh, PA Neiger Design Inc.; Evanston, IL Subsequent to the interviews, and after further due diligence and clarification, the selection committee recommended t the web site development team of Blender box , Inc., of Brooklyn, New York as the preferred firm for developing a website for the Cleveland Street District, subject to successful negotiation of contract terms. The major determinants of the decision were: 1) Expertise in website design, particularly experience with sites created for downtown retail and entertainment districts; 2) Qualifications of the firm and key personnel assigned to the Cleveland Street District website development project; 3) Technical approach to project most compatible with CRA objectives for the project; 4) Effective marketing approach for the new website; and 5) Thorough understanding of the scope of work and needs for the Cleveland Street District in downtown Clearwater. Funds for this contract are provided in the Retail Attraction/Assistance Project Account 94852, which includes a $100,000 item for this project. In response to questions, CRA Executive Director Rod Irwin said the project was not integrated with the RFP for tourism because it was underway before the RFP was released. Economic Development and Housing Director Geri Campos Lopez said the RFP for tourism is for citywide marketing, while this project is for the CRA and will focus on Downtown. Finance Director Margie Simmons said there is a limited exception for CRA 2010-07-13 Item #6I Attachment number 1 Page 7 of 9 not going out to bid. Since the RFP for this project was released, staff must pursue a separate RFP for the citywide tourism. Information Technology Director Dan Mayer said the user-friendly website will not be large. The city does not intend to maintain the website. The platform and programs running are not a beta site. Trustee John Doran moved to approve contract between the CRA and Blenderbox, Inc., Brooklyn, New York, in the amount of $75,000, plus 10% contingency, for a total project approval of $82,500 for design, content development, copy writing and staff training services in conjunction with the development of a Cleveland Street District Marketing and Informational Website, and authorize the appropriate officials to execute the contract for same. The motion was duly seconded and carried unanimously. The purpose of this Development Agreement is to secure economic assistance through the Community Redevelopment Agency (CRA) to increase the economic feasibility of a project which supports the implementation of the City of Clearwater's "District Vision" for the revitalization of the CRA area, and to further the implementation of the Downtown Redevelopment Plan by the development and construction and operation of the project to enhance the quality of life, increase employment and improve the aesthetic and useful enjoyment of the downtown. This agreement provides CRA funding of a $50,000 restaurant build-out, loan-to- grant generally "mirroring" the DDB Restaurant Relocation Program, which provides for incentive reimbursement funding of $1 for every $1 expended on eligible restaurant build-out expenses up to a maximum of $50,000. Since the project involves the relocation and expansion of an existing restaurant within the Cleveland Street District, rather than a new restaurant coming to the District, the DDB Restaurant Relocation grant is not available. Staff supports CRA participation in this project for four reasons. First, Tony's is an established, successful restaurant in the District that indicates the likelihood of continued successful operation at the new location. Second, Tony's seeks to significantly expand their restaurant and develop a full-service component CRA 2010-07-13 Item #71 Attachment number 1 Page 8 of 9 compatible with the CRA restaurant recruitment strategy. Third, the cost of the tenant improvements necessary to install a kitchen and associated facilities are significant and unlikely to be affordable without incentive financing. Finally, the ability/willingness of the owner to fund and move forward with the project at this time of economic downturn, with the assistance delineated above, is very helpful in maintaining our redevelopment momentum. We believe facilitation of this project will keep a proven business in the District and further our objective of expanding quality restaurant space on Cleveland Street. The incentives is to be structured as a five-year "forgivable" loan, secured with a performance mortgage, with 20 % "forgiven" annually as long as the property continues to be used as a full-service restaurant. If it ceases to be so operated during the five-year period, the owner will have to reimburse the CRA for the outstanding balance. Similarly, if the property is sold during the five-year period, the outstanding balance will become due and payable to the CRA, unless the CRA agreed to the assumption of the development agreement by the new owner. The source of funds will be the CRA Retail Attraction /Assistance Project Account 94852.A concept rendering and interior site plan is provided. The design is to be an exhibit to the Agreement. The Development Agreement requires that any substantive change to the design or interior site plan is to be subject to CRA approval. Concern was expressed regarding the use of sandwich board signs on Cleveland Street. Planning and Development Director Michael Delk said staff has not been aggressively enforcing the issue due to Council's direction to work with the Chamber in drafting an ordinance to allow sandwich board signs. Trustee George N. Cretekos moved to approve a Development Agreement between the CRA and Mainstreet Clearwater Development LLC of Clearwater, Florida concerning the Tony's Pizza Restaurant project, 426 to 428 Cleveland Street, delineating the terms and conditions for the provision of certain economic assistance by the CRA. The motion was duly seconded and carried unanimously. CRA 2010-07-13 Item #8I Attachment number 1 Page 9 of 9 r The meeting was adjourned at 9:53 a.m. Chair Community Redevelopment Agency Attest City Clerk CRA 2010-07-13 Item #91 Meeting Date: 8/16/2010 Pension Trustees Agenda Council Chambers - City Hall SUBJECT / RECOMMENDATION: Approve the sub-advisory relationship between Wentworth, Hauser and Violich, Inc. and Hirayama Investments and authorize appropriate officials to execute same. SUMMARY: In April 2008, the Employees' Pension Plan hired and started funding Wentworth, Hauser and Violich, Inc. (WHV) as a large cap international equity (EAFE) manager. WHV has reorganized and created a sub-advisory company, Hirayama Investments, to manage the large cap international equity fund in which the City participates. The investment team the plan hired in 2008 has remained the same. The structure of the organization is the only change being made. The Pension Investment Committee supports the change and the pension plan's attorney has reviewed and approved the sub-advisory agreement. Type: Current Year Budget?: Budget Adjustment Comments: Current Year Cost: Not to Exceed: For Fiscal Year: Other None Budget Adjustment: Annual Operating Cost: Total Cost: to None 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 # 2 Attachment number 1 Page 1 of 2 I ". October 20, 2009 Mr. William B. Horne II, City Manager c/o Mr. Steve Moskun Cash and Investments Manager City of Clearwater 112 South Osceola Avenue Clearwater, FL 33756-5106 Re: CITY OF CLEARWATER EMPLOYEES' PENSION PLAN INTERNATIONAL EQUITY Dear Mr. Horne: As a follow up to the announcement letter sent last fall, we are pleased to inform you that the joint venture between Wentworth, Hauser and Violich, Inc. ("WHV") and Hirayama Investments, LLC, our affiliated SEC registered investment adviser, has been completed as of January 1, 2009. Hirayama Investments is co-owned by WHV and your portfolio manager, Richard Hirayama. WHV and Hirayama Investments have entered into a ten year sub-advisory agreement whereby Hirayama Investments will provide international and global equity portfolio management services exclusively to WHV's clients. As a current WHV client in the International or Global Equity Portfolio, we assure you that there have been no changes in the investment strategy, portfolio management or client servicing of your account. Your International or Global Equity Portfolio is under the same management with the same long- standing investment philosophy, guidelines and goals currently in place. In order for your client relationship with both firms to be formalized, we respectfully request your consent to the sub-advisory relationship between WHV and Hirayama Investments by signing, dating and returning a copy of the addendum below at your earliest convenience. Returning a signed copy by fax is sufficient. Please note that this is not an assignment of our investment management agreement with you, but rather an addendum that authorizes the sub-advisory relationship between our two firms. We value our relationship and look forward to meeting your ongoing investment management requirements. If you have any questions, please do not hesitate to contact us. Sincerely, W. Kurt Hauser Richard K. iChief Executive Officer Managing Member Wentworth, Hauser and Violich, Inc. Hirayama Investments, LLC 301 Battery Street I Suite 400 1 San Francisco, CA 94111 Tel 415.981.6911 Fax 415.288.6190 1 A@fflA2Drn Attachment number 1 Page 2 of 2 Investment Management Agreement Addendum Wentworth, Hauser and Violich may delegate its discretionary authority under the Investment Management Agreement with CITY OF CLEARWATER EMPLOYEES' PENSION PLAN to Hirayama Investments, LLC. Hirayama Investments, LLC will provide International and Global Equity portfolio management services to Wentworth, Hauser and Violich under a separate sub-advisory agreement. Wentworth, Hauser and Violich will continue to provide investment management services directly to CITY OF CLEARWATER EMPLOYEES' PENSION PLAN. Other than the above, all remaining provisions of the Investment Management Agreement continue in full force and effect. ACCEPTANCE: Countersigned: By: William B. Horne II City Manager Date Approved as to form: Printed name: Pension Attorney Date CITY OF CLEARWATER, FLORIDA Attest: Cynthia E. Goudeau City Clerk Date Item # 2 Meeting Date: 8/16/2010 Pension Trustees Agenda Council Chambers - City Hall SUBJECT / RECOMMENDATION: Approve hiring MEPT as a core real estate manager for the Employees Pension Plan, authorize a contract with New Tower Trust as the trustee and authorize the appropriate officials to execute same. SUMMARY: Earlier this year, the Trustees authorized staff to conduct a search for a core real estate manager. Cap Trust the plan's consultant assisted with the search. Cap Trust generated a list of seventy-five potential real estate managers. The list was pared down to eliminate managers with excessive debt, oversized redemption queues, significant style deviation, lack of staff and depth, limited investment capacity, and problematic geographic distribution. Funds that did not meet the definition of a open ended core domestic fund were also eliminated. These criteria reduced the list of potential managers to twelve. The remaining twelve managers answered a thirty-page questionnaire with one hundred and eighty questions. Based on the fund manager's answers to those questions the list was reduced to the following six managers that was presented to the Pension Investment Committee. American Core Reality Fund Cornerstone Property Fund MEPT TIAA-CREF- Core Properties Fund ING Lion Properties Fund UBS Turnbull Property Fund The Pension Investment Committee reduced the list to the top four listed potential managers and received presentations from the four firms. All of the candidates that presented to the Pension Investment Committee were high quality firms. MEPT is being recommended over the other firms for a variety of reasons, which include its track record, length of time in business, quality and size of its portfolio, organizational structure and for its ability to weather market downturns and other unforeseen events. MEPT is highly regarded in the industry and has the recommendation of both of the plans consultants and a unanimous recommendation of the Pension Investment Committee. MEPT was founded April 1, 1982 and is organized as a bank collective trust, which is maintained by New Tower Trust Company. The Fund is managed by three entities: Kennedy Associates Real Estate Counsel, LP, of Seattle, Washington, serves as the real estate investment advisor, Landon Butler & Company, LPO, provides investor relations and marketing services to MEPT, and New Tower Trust Company serves as the trustee and fiduciary of the Fund. Our contract is with New Tower since they are the fiduciary for the fund. The Pension Plan attorney has approved this contract. Funding for MEPT will come from a reduction in the allocation to out REIT manager. The dollar amount of the plan's exposure to real estate will remain the same. The addition to MEPT increases the diversification of this asset class specifically and of the plan in general. Northern Trust, the plan's custodian will assist with the transition. Review 1) Financial Services 2) Office of Management and Budget 3) Legal 4) Clerk 5) Assistant City Man 6*gerk 7) City Approval: Manager 8) Clerk Attachment number 1 Page 1 of 14 NEWTOWER I It U IN 1 N4 1' A N Y MULTI-EMPLOYER PROPERTY TRUST PARTICIPATION AGREEMENT This Participation Agreement is made this day of , 20-. between NewTower Trust Company, as trustee ("Trustee") and , the fiduciary who is named or identified as a fiduciary under section 402(a)(2) of the Employee Retirement Income Security Act of 1974, as amended ("ERISA"), or other person authorized to enter into this Participation Agreement ("Named Fiduciary") on behalf of WITNESSETH: ("Participant") WHEREAS, the Multi-Employer Property Trust (the "Trust") was established as a collective investment fund pursuant to the Declaration of Trust dated June 22. 1981, as amended and restated as of October 31, 2003, and further amended as of June 14, 2005. for the purpose of providing a collective investment vehicle for investments in Real Estate Investments by Qualified Participants; and Item # 3 Attachment number 1 Page 2 of 14 WHEREAS, Participant is a Qualified Participant, and, as determined by Named Fiduciary, desires to become a Participant in the Trust; NOW, THEREFORE, in consideration of the promises and of the mutual agreements herein contained, Named Fiduciary, on behalf of Participant, and Trustee agree as follows: ARTICLE I Section 1.1 Definitions. Unless otherwise specified herein, any capitalized word or phrase shall have the same meaning as set forth in the Declaration of Trust. ARTICLE 11 Section 2.1 Appointment as Trustee. Named Fiduciary hereby appoints NewTower Trust Company as Trustee, to hold in trust, as fiduciary, on behalf of Participant such sums of money. or other property of Participant, together with all earnings, profits. increments, and accruals thereon, as shall be received from time to time by Trustee from any source, and to invest and reinvest the same without distinction between principal and income and to make payment therefrom. subject to the provisions of this Participation Agreement. Trustee hereby accepts this appointment and acknowledges that it is a "fiduciary" and "investment manager" within the meaning of Title I of E:RISA. with respect to monies or property of Participant deposited hereunder with Trustee. The terms of such appointment shall be as set forth herein. Trustee shall be responsible only far those funds as are actually received by it for the account of Participant. Trustee shall Item # 3 Attachment number 1 Page 3 of 14 receive and credit to Participant's account, without distinction between principal and income, all dividends and interest paid on securities at any time held therein. Section 2.2 Authority of Trustee. Trustee hereby confirms and represents to Participant that Trustee is duly authorized to enter into this Participation Agreement and to accept any and all sums of money or other property of Participant as may be contemplated hereby, that the legal instruments creating or embodying such authorization are valid and in full Force and effect, and that any ether actions necessary to authorize Trustee to enter into this Participation Agreement have been duly taken. Trustee will immediately notify Participant if authority is revoked or rescinded. "Trustee will immediately notify Participant in writing if any statement made in this Section 2.2 changes and will provide Participant with current correct information. Section 2.3 Qualified Professional Asset Manager. The Trustee is a "qualified professional asset manager" within the meaning of Part V of Prohibited Transaction Class Exemption 84-14, and any successor exemption or regulation. ARTICLE III Section 3.1 Qualification of Participant. Named Fiduciary hereby warrants that Participant is and shall remain exempt from Federal income taxes under section 501(a) of the Code, by reason of qualifying under section 401(a) of the Code, or is an entity otherwise permitted under law to participate in the Trust, but only to the extent the requirements of section 584 of the Internal Revenue Code, and applicable regulations of the Comptroller of the Currency will continue to be satisfied. Named Fiduciary shall -3- Item # 3 Attachment number 1 Page 4 of 14 simultaneously with the execution of this Participation Agreement furnish to "Trustee a copy of the latest determination letter issued by the Internal Revenue Service pursuant to which such exempt status of Participant has been granted; or a copy of the request for such determination letter accompanied by an opinion of counsel that Participant meets the requirements for approval of tax-exempt status under section 401(a) of the Code; or an opinion of counsel that Participant is otherwise qualified to participate in the Trust. If'a determination letter has been requested, Named Fiduciary shall furnish to Trustee a copy of the determination letter upon its receipt from the Internal Revenue Service. Section 3.2 Authority of Named Fiduciary. Certain Information. Named Fiduciary hereby confirms and represents to the Trustee that Named Fiduciary is duly authorized. by its governing trust agreement and such other documents as may be applicable. to enter into this Participation Agreement and to transfer to Trustee any and all such sums of money as may be contemplated hereby, that the legal instruments creating or embodying such authorization are valid and in full force and effect. and that any other actions necessary to authorize Named Fiduciary to enter into this Participation Agreement have been duly taken. Named Fiduciary immediately will notify Trustee if such authority is revoked or rescinded. Concurrent with the execution hereof, Named Fiduciary is delivering to the Trustee a true and correct statement evidencing the proper legal name of Named Fiduciary, its address, and the names of its administrators, legal counsel, and all trustees. if any change occurs in such information. Named Fiduciary immediately will so notily Trustee in writing, providing current correct information. -4- Item # 3 Attachment number 1 Page 5 of 14 Section 3.3 Notice of Disqualification. In the events that: (a) Participant receives notice from the internal Revenue Service that Participant's tax-exempt status has been revolved, terminated, or modified, so that Participant is no longer exempt from Federal income tax under the Internal Revenue Code, (b) the Participant's governing instrument is amended or altered so as to no longer authorize investment in the Trust, or (c) Participant does not receive a favorable determination letter from the Internal Revenue Service. if applicable, or (d) Participant is for any reason no longer eligible to participate in the Trust, Named Fiduciary shall provide notice of such revocation, amendment. unfavorable determination, or modification to Trustee within 15 days of its execution. Upon receipt of such notice, Participant's Participation in the Trust shall thereupon be withdrawn in accordance with the provisions of the Declaration of Trust. Section 3.4 Exclusive Investment Policy. The Trust shall be operated and maintained for investment by Qualified Participants. The Trust's investment of jcctive is to provide Qualified Participants with investment opportunities through holdings primarily in Real Estate Investments. The Trust shall not be bound by any other investment policy or by any investment guidelines applicable to individual Qualified Participants. ARTICLE IV Section 4.1 Receipt of Documents. Named Fiduciary acknowledges that it has received and reviewed the Declaration of Trust For The Multi-Employer Property Trust, as amended and restated effective October 31, 2003 and as further amended as of June 14. 2005, the May 27, 1981 determination letter from the Internal Revenue Service concerning -5- Item # 3 Attachment number 1 Page 6 of 14 the qualification of the Trust under section 584 of the Internal Revenue Code: and the most recent audited financial statements of the Trust. Section 4.2 Informed Decision. Named Fiduciary acknowledges that it has been given the opportunity to review with Trustee the tenns and conditions of this Participation Agreement and the Declaration of Trust. Named Fiduciary further acknowledges that it has carefully considered the advisability of an investment of assets in the Trust, has taken into account the fact that funds in the Trust are invested principally or exclusively in real estate and that the value of such real estate may be affected positively or negatively by a variety of factors, has determined, after due deliberation, and based solely upon independent investigations made, directly or indirectly, that an investment by Participant of a portion of the assets of Participant in the Trust is consistent with Named Fiduciary's duties to diversify the Participant's assets and to invest such assets with care, skill. prudence and diligence. and has determined that such investment by Participant is legal and permissible in all respects and that all other actions required to authorize Participant to make such investment have been duly taken. Named Fiduciary further acknowledges and understands that (i) although the Trust will seek diversification in types of property, as well as location and other characteristics, the Trust's portfolio may, at any given time. not he diversified, (ii) the Trustee shall not be under an obligation to effect or maintain the diversification of the Participant's assets; (iii) the Units have not been registered under the Securities Act of 1933. as amended, and (iv) the Trust has not been registered under the Investment Company Act of 1940, as amended. -6- Item # 3 Attachment number 1 Page 7 of 14 Section 4.3 Reaffirmation of Re resentations. Each additional contribution of funds by Participant to the Trust small constitute a reaffirmation by Named Fiduciary that The representations contained herein are true and correct on and as of the date each such additional contribution is made. ARTICLE V Section 5.1 Records; Securities Registration. At all times, monies. securities and other funds held for the Participant's account shall be clearly recorded and identified on the Trustee's books and records as being held in trust for Participant. Any such securities at any time held under this Participation Agreement may be registered in the name of one of the Trustee's nominees for the purpose of convenience, or may be held unregistered or in such form as to pass by delivery. and the Trustee's liability or responsibility shall be neither increased nor decreased by such registration or holding. In connection with the safe-keeping, of'such securities and other funds. Trustee shall assume complete responsibility for all acts or failure to act of any of its officers, employees, or agents and for the furnishing of such vaults and the employment of such security precautions and procedures as are practicable and appropriate. Section 5.2 Trustee's Investment Powers. Pending the investment of monies or properties deposited hereunder in Units of the Trust, Trustee shall have the duty, power, and authority to invest and reinvest. without distinction between principal and income, the monies and properties of the Participant held from time to time hereunder in such mortgages, loans. bonds, common stocks, certificates of deposit, treasury bills and notes, -7- Item # 3 Attachment number 1 Page 8 of 14 bankers' acceptances, other government or private corporate debt securities, common trust funds and commingled or collective investment funds, money market mutual funds- repurchase agreements and short-term investment funds, including those offered through Trustee, as "Trustee in its sole discretion shall deem proper and suitable without complying with the requirements or customs for investments of trust funds under the law, rules. or regulations prevailing in any jurisdiction in which this Trust may be effective. and in so seeking. any such investments, Trustee shalI exercise the care, skill, prudence. and diligence under the circumstances then prevailing that a prudent man acting in a like capacity and familiar with such matters would use in the conduct of any enterprise of a like character and with like aims. It is understood that the monies and property deposited hereunder, along with any earnings thereon, will be invested in the Trust as soon as permitted by the Declaration of Trust creating the Trust. Section 5.3 Termination. This Participation Agreement shall terminate upon the complete withdrawal of the Participant's Participation in the 'T'rust. Section 5.4 Fees to Trustee. Participant shall pay to Trustee for its services hereunder compensation in accordance with the Statement of Compensation and any amendments thereto. Such compensation shall be payable out of the principal and income of the Trust allocable to Participant. Nothing hereunder shall obligate Participant to pay any fee (other than the fee imposed pursuant to the Statement of Compensation) with respect to monies invested in the Trust. _g_ Item # 3 Attachment number 1 Page 9 of 14 All taxes of any or all kinds whatsoever which may be levied or assessed under existing or future laws upon, or in respect of. the assets held hereunder or the income therefrom shall be paid from the Participant's account. Section 5.5 Authority. A third party dealing with Trustee shall not make. or be required by any person to make, any inquiry as to whether Trustee has authority tcf take or omit any action under this Participation Agreement. Section 5.6 Reliance b Trustee. 'T'rustee shall be fully protected in acting upon any instrument, certificate or paper, reasonably believed by it to be yenuine and to have been signed and presented by the proper person or persons, and Trustee shall be under no duty to make any investigation or inquiry as to any statement contained in any such writing, but may accept the same as conclusive evidence of the truth and accuracy of the statement therein contained. Section 5.7 Successors. Any corporation or association which shall by merger. consolidation, purchase, or otherwise, succeed to substantially all the trust business of Trustee, or which is appointed as successor Trustee of the Trust in accordance with the Declaration of Trust, shall, upon such succession and without any appointment or other action by any person, be and become successor Trustee hereunder and shall be bound by all the terms and provisions of this Participation Agreement. Notice of such succession will be given to Participant as legally permissible. Section 5.8 Inco oration of Declaration of Trust. All terms and provisions of the Declaration of Trust creating the Multi-Employer Property Trust are herein incorporated by reference. The Statement of Compensation attached to this Participation Agreement is -9- Item # 3 Attachment number 1 Page 10 of 14 also incorporated. If any prevision hereof and of the Declaration of Trust shall be in conflict. the terms of the Declaration of Trust shall govern. Any amendment to the Declaration of Trust shall be automatically incorporated by reference herein. Section 5.9 Amendments. Amendments to this Participation Agreement must be made by the mutual written agreement of the parties. Section 5.14 Withdrawals and Other Distributions. Upon request of Participant, Trustee will take such action as is necessary to exercise, on behalf of Participant. the withdrawal rights or any other rights of Participant under the Declaration of Trust_ Trustee will promptly distribute and pay over to Participant any distributions made by the Trust with respect to the Participant's Participation in the 'T'rust. Section 5.11 Severability. If any one or more of the covenants, agreements. provisions or terms of this agreement shall be held contrary to policy of express law. although not expressly prohibited. or against public policy, or shall for any reason whatever be held invalid, then such covenants, agreements, previsions and terms shall be deemed severable from the remaining; covenants. agreements, provisions and terms of this Participation Agreement and shall in no way effect the validity or enforceability of the other provisions of this Participation Agreement. Section 5.12 Additional Documents. Named Fiduciary shall deliver to the Trustee any and all docurnents reasonably requested from time to time. Suction 5.13 Governing Laws. This Participation Agreement and the trust created hereby, and the rights and obligations of persons affected thereby, shall be construed and determined in accordance with applicable Federal law to the extent such law supersedes - 10- Item # 3 Attachment number 1 Page 11 of 14 applicable laws. of the state of Mary land and shall be construed under the Iaws ofthe state of Maryland to the extent federal law is inapplicable or does not supersede Maryland law. For purposes of the preceding sentence, the term "law" small include applicable judicial or administrative decisions, rules, and regulations. All transfers of property to the Trustee shall be deemed to take place in Maryland. IN WITNESS WHEREOF, Participant, by its duly authorized agents or representatives, has executed this Participation Agreement, and NewTower Trust Company has caused this Participation Agreement to be executed in its corporate name and its corporate seal to be hereunto affixed and duly attested, by its duly authorized officers, this day of ,20-, PARTICIPANT (Full Legal Name) By By By ATTUIST: NewTower Trust Company By? By -11- ? Item # 3 Attachment number 1 Page 12 of 14 Its 1• j 'r'r f ?? ; r ' { Iii 7l 4 Its JCORPORATE SI AL] 0018-001 p1041508 9/6/06 - 12 - Item # 3 Attachment number 1 Page 13 of 14 Countersigned: By: William B. Horne 11 City Manager Approved as to form: J ..? IV ?X Pension Attorney CITY OF CLEARWATER, FLORIDA Attest: Cynthia E. Goudeau City Clerk Item # 3 Attachment number 1 Page 14 of 14 NEWTOWEk- 'I IL l_f 5 I' c' t 7 ,N1 1' A N Y STATEMENT OF COMPENSATION NewTower Trust Company (the "Bank"), as Trustee of the NewTower Trust Company Multi- Employer Property Trust (the "Property Trust"), shall be entitled to an annual fee for the management and administration of the PropertyTrust of 1.25% of the first $1 billion of Property -Trust net assets, 1.00% of the second $1 billion of Property Trust net assets, and 0.75% of Property Trust net assets above $2 billion. Cash balances in excess ?f 7.5% of Property Trust net assets are excluded from the above fee calculation and will be subject to an annual fee of 0.15%. These fees shall be charged against the Property Trust can a monthly basis The Property Trust shall bear, in addition to the Bank's compensation, only those costs and expenses payable in accordance with the Declaration of Trust. No indirect or overhead expenses of the Bank shall be reimbursed by the Property Trust. PARTI CIPANT: (Ful I Legal Name) - - ACKNOWLEDGED: Its: Its: Date: Date: By Its: Date: s f;: ii,rti,i.. i?iru?: [ -.•,:r:,. ti::ac Er,its? 13„I,,•-.?i:,- .?lE ? ?i??.l { Item # 3 Attachment number 2 Page 1 of 3 City of Clearwater Employees' Pension Plan Open End Core Real Estate Fund Manager Search Executive Summary The City of Clearwater Core Real Estate search was conducted by CapTrust Advisors, LLC (CapTrust) on behalf of the City of Clearwater Employees' Pension Plan Investment Committee. An initial notice of the search was circulated to several national media sources and industry publications in January of this year. CapTrust received a wide range of responses from these publications and all inquiries were directed to CapTrust's website where managers registered for the search. CapTrust also screened several industry databases and generated a list of seventy-five potential real estate managers. Preliminary Selection CapTrust forwarded an abridged questionnaire that covered basic characteristics aimed at exploring the health of the real estate funds under review. With this brief questionnaire, CapTrust contacted a wide number of funds and performed a preliminary filter. Funds were removed from consideration for a number of reasons. For example, CapTrust eliminated strategies with excessive debt, oversized redemptions queues, lack of staff and depth, funds with significant style deviation, limited investment capacity, excessive headline risk and problematic geographic distribution. Funds that did not meet our definition of a core domestic fund were also eliminated from consideration. Primary Due Diligence From the initial responses to the abridged questionnaire, CapTrust selected funds for follow up calls to narrow down the pool of managers. The identified group of potential real-estate managers were called to learn about each of the firms and ascertain the differences in each fund's strategy. Each call was documented to maintain a record of the dialogue and material covered in the interview. CapTrust analysts and consultants took part in revising our internal real estate due diligence questionnaire to address many of the concerns in the current market environment. Once CapTrust identified a potential set of real-estate funds, it issued an enhanced, thirty-page real estate-focused due diligence questionnaire, consisting of 180 questions, which was issued to twelve organizations. Notable organizational sections within the questionnaire were: personnel turnover, incentive structures, ethics and compliance violations, valuation policies and techniques, background and experience of management, the investment approach, the research process, and the roles and responsibilities of the investment team. Aside from the broad organizational and process information, we looked deeper into the specific strategy requesting a timeline of purchase and sales of properties over the past ten years, tables showing property Item # 3 Attachment number 2 Page 2 of 3 diversification, use of leverage, debt pay down schedules and lease roll schedules. The finished questionnaires were returned to CapTrust as seventy- to ninety-page responses along a few hundred pages in supporting material. CapTrust Due Diligence Interviews After receiving and reviewing the responses, CapTrust set up several follow up calls to cover the due diligence questionnaires with each of the preliminary firms. Once all questions pertaining to the questionnaire were satisfied, further calls were made to specifically recap each fund's specific strategy and outlook. Once the review of the questionnaires was complete, CapTrust maintained contact with each of the funds leading up to the search presentations. Calls were established on a bi-monthly basis to monitor each of the funds' capacity and check for any updates on strategy. The search was quite exhaustive and meticulous and yielded a group of Core Real Estate managers which CapTrust felt was fully-vetted and had a high degree of confidence in when presenting candidates to the City's Finance Committee. Presentation to the Investment Committee On May 14, 2010, CapTrust presented its findings to the Investment Committee. Essential details were disclosed and discussed regarding six recommended real estate collective funds. The recommendations included: American Core Realty Fund Cornerstone Property Fund ING Lion Properties Fund MEPT Property Trust TIAA-CREF Core Properties Fund UBS Turnbull Property Fund Based on the quantitative and qualitative information provided, the Committee selected the following four funds as finalists to be invited to give personal presentations to the Investment Committee: American Core Realty Fund Cornerstone Property Fund MEPT Property Trust TIAA-CREF Core Properties Fund Final Selection by the Investment Committee Presentations were made to the Investment Committee on June 9, 2010 and June 10, 2010. All of the candidates were regarded as high-quality alternatives that could be chosen for the mandate. However, it was agreed that a single manager was the most appropriate approach at this time. MEPT was chosen over the other finalists for a variety of reasons which included its Item # 3 Attachment number 2 Page 3 of 3 track record, length of time in the business, quality and size of its portfolio, organizational structure and perceived ability to weather market downturns and other unforeseen contingencies. Item # 3 Meeting Date: 8/16/2010 Pension Trustees Agenda Council Chambers - City Hall SUBJECT / RECOMMENDATION: Accept new hires into Pension Plan. SUMMARY: Pension Elig. Name, Job Classification, & Department/Division Hire Date Date Cliff Norris, Recreation Supervisor I/Parks & Recreation 4/3/80 6/10/10 * * originally hired on 4/3/80 and denied pension; reexamined and pension eligible as of 6/10/10 Review Approval: 1) Human Resources Cover Memo Item # 4 Meeting Date: 8/16/2010 Pension Trustees Agenda Council Chambers - City Hall SUBJECT / RECOMMENDATION: Approve employee requests for regular pensions. SUMMARY: Jeanette Paterkiewicz, Staff Assistant, Public Utilities Department, was employed by the City on August 7, 1989, 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 $36,007 per year over the past five years, the formula for computing regular pensions, and Ms. Paterkiewicz' selection of the Joint & Survivor Annuity, this pension will approximate $20,775 annually. Diana Henderson, Police Service Technician, Police Department, was employed by the City on December 4, 1989, 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 $44,128 per year over the past five years, the formula for computing regular pensions, and Ms. Henderson's selection of the Joint & Survivor Annuity, this pension will approximate $25,170 annually. Charles Maybin, Parks Service Technician III, Parks & Recreation Department, was employed by the City on January 15, 1990, 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 $43,471 per year over the past five years, the formula for computing regular pensions, and Mr. Maybin's selection of the 75% Joint & Survivor Annuity, this pension will approximate $24,643 annually. Sandra Herman, Planner III, Planning & Development Department, was employed by the City on January 27, 1986, 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 $70,352 per year over the past five years, the formula for computing regular pensions, and Ms. Herman's selection of the Life Annuity, this pension will approximate $52,195 annually. Beverly Verner, Staff Assistant, Parks & Recreation Department, was employed by the City on November 4, 1985, 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 $35,120 per year over the past five years, the formula for computing regular pensions, and Ms. Verner's selection of the Joint & Survivor Annuity, this pension will approximate $23,742 annually. Julia Jablonski, Solid Waste Program Coordinator, Solid Waste/General Services Department, was employed by the City on December 28, 1987, and her pension service credit is effective on February 22, 1988. Her pension will be effective August 1, 2010. Based on an average salary of approximately $52,463 per year over the past five years, the formula for computing regular pensions, and Ms. Jablonski's selection of the Joint & Survivor Annuity, this pension will approximate $32,377 annually. Carl Swigart, Solid Waste Supervisor I, Solid Waste/General Services Department, was employed by the City on February 12, 1981, and his pension service credit is effective on that date. His pension will be effective December 1, 2010. Based on an average salary of approximately $54,412 per year over the past five years, the formula for computing regular pensions, and Mr. Swigart's selection of the 100% Joint & Survivor Annuity, this pension will approximate $43,533 annually. Alison Johnson, Storeskeeper, Public Utilities Department, was employed by the City on February 2, 1987, and her pension service credit is effective on that date. Her pension will be effective August 1, 2010. Item # 5 Based on an average salary of approximately $41,621 per year over the past five years, the formula for computing regular pensions, and Ms. Johnson's selection of the Life Annuity, this pension will approximate $28,390 annually. Sandra Howard, Customer Service Accounting Representative, Customer Service Department, was employed by the City on March 26, 1984, 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 $38,400 per year over the past five years, the formula for computing regular pensions, and Ms. Howard's selection of the Joint & Survivor Annuity, this pension will approximate $27,820 annually. Kate MacDonald, Police Information Technician II, Police Department, was employed by the City on November 10, 1986, and her pension service credit is effective on that date. Her pension will be effective September 1, 2010. Based on an average salary of approximately $40,254 per year over the past five years, the formula for computing regular pensions, and Ms. MacDonald's selection of the Joint & Survivor Annuity, this pension will approximate $26,300 annually. William Fairchild, Public Utilities Technician H, Public Utilities Department, was employed by the City on May 23, 1988, 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 $47,694 per year over the past five years, the formula for computing regular pensions, and Mr. Fairchild's selection of the Joint and Survivor Annuity, this pension will approximate $29,197 annually. William Kunzman, Parking Enforcement Specialist, Engineering Department, was employed by the City on March 23, 1987, and his pension service credit is effective on March 31, 1987. His pension will be effective August 1, 2010. Based on an average salary of approximately $40,514 per year over the past five years, the formula for computing regular pensions, and Mr. Kunzman's selection of the Life Annuity, this pension will approximate $31,779 annually. Steven Grasso, Tradesworker, Marine & Aviation Department, was employed by the City on October 7, 1982, and his pension service credit is effective on January 5, 1985. His pension will be effective September 1, 2010. Based on an average salary of approximately $47,289 per year over the past five years, the formula for computing regular pensions, and Mr. Grasso's selection of the Joint and Survivor Annuity, this pension will approximate $33,349 annually. Rick Mishler, Utilities Mechanic, Public Utilities Department, was employed by the City on June 17, 1985, 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 $55,615 per year over the past five years, the formula for computing regular pensions, and Mr. Mishler's selection of the 75% Joint & Survivor Annuity, this pension will approximate $38,642 annually. Patricia Warren, Administrative Support Manager, Information Technology Department, was employed by the City on July 17, 1978, and her pension service credit is effective on that date. Her pension will be effective September 1, 2010. Based on an average salary of approximately $55,199 per year over the past five years, the formula for computing regular pensions, and Ms. Warren's selection of the Joint & Survivor Annuity, this pension will approximate $48,743 annually. Douglas King, Drafting & Mapping Technician, Engineering Department, was employed by the City on June 12, 1978, 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 $43,945 per year over the past five years, the formula for computing regular pensions, and Mr. King's selection of the Life Annuity, this pension will approximate $42,601 annually. Richard Hamilton, Professional Land Surveyor, Engineering Department, was employed by the City on January 6, 1975, and his pension service credit is effective on July 7, 1975. His pension will be effective August 1, 2010. Based on an average salary of approximately $59,599 per year over the past five years, the formula for computing regular pensions, and Mr. Hamilton's selection of the 100% Joint & Survivor Annuity, this pension will approximate $55,704 annually. John Richter III, Construction Inspector II, Engineering Department, was employed by the City on June 30, 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 $44,049 per year over the past five years, the formula for computing regtQWTb inns, and Mr. Richter's selection of the 100% Joint & Survivor Annuity, this pension will approximate $35,635 annually. Item # 5 Jerry Williams, Solid Waste Equipment Operator, Solid Waste/General Services Department, was employed by the City on August 20, 1980, 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 $35.687 per year over the past five years, the formula for computing regular pensions, and Mr. Williams' selection of the Joint & Survivor Annuity, this pension will approximate $29,442 annually. Russell Dunning, Public Services Technician III, Public Services Department, was employed by the City on May 21, 1990, and his pension service credit is effective on January 31, 1998. His pension will be effective September 1, 2010. Based on an average salary of approximately $45,942 per year over the past five years, the formula for computing regular pensions, and Mr. Dunning's selection of the 10-Year Certain and Life Annuity, this pension will approximate $15,054 annually. Barbara Schill, Senior Accountant, Finance Department, was employed by the City on June 19, 2000, and her pension service credit is effective on that date. Her pension will be effective September 1, 2010. Based on an average salary of approximately $45,736 per year over the past five years, the formula for computing regular pensions, and Ms. Schill's selection of the Joint & Survivor Annuity, this pension will approximate $12,815 annually. Gary Johnson, 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 $61,596 per year over the past five years, the formula for computing regular pensions, and Mr. Johnson's selection of the 10-year Certain & Life Annuity, this pension will approximate $33,878 annually. Larry Harbert, 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 $68,614 per year over the past five years, the formula for computing regular pensions, and Mr. Harbert's selection of the Joint & Survivor Annuity, this pension will approximate $37,738 annually. Robert Fava, Police Officer, Police Department, was employed by the City on March 29, 1989, 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 $74,450 per year over the past five years, the formula for computing regular pensions, and Mr. Fava's selection of the Joint & Survivor Annuity, this pension will approximate $43,347 annually. James Thomas, Fire Lieutenant, Fire Department, was employed by the City on January 4, 1988, 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 $76,072 per year over the past five years, the formula for computing regular pensions, and Mr. Thomas' selection of the 10-year Certain & Life Annuity, this pension will approximate $50,341 annually. Mark Beaudette, Police Officer, Police Department, was employed by the City on May 17, 1989, 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 $70,139 per year over the past five years, the formula for computing regular pensions, and Mr. Beaudette's selection of the 100% Joint & Survivor Annuity, this pension will approximate $40,286 annually. Robert Wierzba, Police Sergeant, Police Department, was employed by the City on March 23, 1987, 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 $96,958 per year over the past five years, the formula for computing regular pensions, and Mr. Wierzba's selection of the 100% Joint and Survivor Annuity, this pension will approximate $61,931 annually. Norman Jernigan, Fire Medic Lieutenant, Fire Department, was employed by the City on January 6, 1986, 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 $80,936 per year over the past five years, the formula for computing regular pensions, and Mr. Jernigan's selection of the 10-Year Certain and Life Annuity, this pension will approximate $54,871 annually. Lawrence Borland, Police Sergeant, Police Department, was employed by the City on October 18, 1982, and his phi mice credit is effective on that date. His pension will be effective September 1, 2010. Item # 5 Based on an average salary of approximately $82,750 per year over the past five years, the formula for computing regular pensions, and Mr. Borland's selection of the 100% Joint and Survivor Annuity, this pension will approximate $61,043 annually. James Houck, Police Officer, Police Department, was employed by the City on April 3, 1989, 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 $66,831 per year over the past five years, the formula for computing regular pensions, and Mr. Houck's selection of the 100% Joint & Survivor Annuity, this pension will approximate $38,744 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 Police Officer, Fire Lieutenant, Police Sergeant, and Fire Medic Lieutenant as meeting the hazardous duty criteria. Ms. Paterkiewiz, Ms. Henderson, Mr. Maybin, Ms. Herman, Ms. Verner, Ms. Jablonski, Mr. Swigart, Ms. Johnson, Ms. Howard, Ms. MacDonald, Mr. Maran, Mr. Fairchild, Mr. Kunzman, Mr. Grasso, Ms. Clement, Ms. Meri, and Mr. Mishler qualify under the age 55 and 25 years of service criteria. Ms. Warren, Mr. King, Mr. Hamilton, Mr. Richter, and Mr. Williams qualify under the 30 years of service criteria. Mr. Dunning and Ms. Schill qualify under the age 65 and 10 years of service criteria. Mr. Johnson, Mr. Harbert, Mr. Fava, Mr. Wilt, Mr. Thomas, Mr. Beaudette, Mr. Wierzba, Mr. Jernigan, Mr. Borland, and Mr. Houck qualify under the hazardous duty criteria. Review Approval: 1) Financial Services 2) Office of Management and Budget 3) Clerk Cover Memo Item # 5 Page 1 of 138 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. an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. EMPL O PEES' SEPARA T/ON PA Y PREFERENCES C/TY OF CLEARI"IATER 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 a qo, D vacation 6 30° qa. sick any 5 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: ?Y 3?tur? PHONE: ?7 }-7 /-7,4--y- DATE: Revised 1/02 Form #!9900-0008 File Name: Employee Separation Pay Pref Item # 5 Page 2 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM I, v ea re-t t-e P hi Pctii c z do hereby apply for retirement under the City of Clearwater General Employees' Pension Plan. Job Classific 'on: s ??'T S S i S`? ?a??'? Sex: M0 Department: I L \ 4-e Division: Benefits Date: 9-,1-71S9 Date of Hire: fs 1 Date of Birth: / y(. Resignation Date: 3 / .o Spouse's Name: Spouse's Date of Birth: Sex: M 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 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 Ann ui 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. [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 # 5 Page 3 of 138 Option b - 100% joint & q ?rvi- 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. If taking Option 1 sian below: Option Description: _Joint and Survivor Annuity Employee's Signature: d / Date: lfJ °1 l Dependent children under the age of 18 and residing in my househol 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 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 foregoin instrument was acknowledged before e this COUNTY OF PINELLAS / (0 ?,( V by _ .f tG ?1 e e. R -r/ i fu): [ who is personally known to me or who has provided as ideZ=0 /dt a an oath. Notary Public -b -4 Q (9na L- Name of Notary Printed My Commission expires: Rev. 4/08 Form #9900-0009 NOTARY PUBLIC-STATE OF FLORI^<; Deborah L. Foru Commission # DD763426 Expires: MAY 15, 2012 BONDED THRU ATLANTIC BONDING CO., INC. File Name: Pension Entitlement Option Form Item # 5 Page 4 of 138 Imo- Estimated Pension Worksheet II Jeanette Paterkiewicz LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 7/30/2010 8/7/1989 20.9806 Signature: _ &kk,4d veca Date: (,/--)h0 GROSS CALENDAR PENSION YEAR EARNINGS 2005 $34,606.33 2006 $35,945.56 2007 $35,795.85 2008 $36,318.41 2009 $37,370.41 $180,036.56 (5 Year Total) 5/ $36,007.31 (Yearly Avg) 12/ $3,000.61 (Monthly Avg) x 0.0275 (Benefit Rate) x 20.9806 (Yrs of Service) $1,731.25 (Est Mtly Pension) Item # 5 Page 5 of 138 CITY OF CLEARVVATER EMPL OYEES' SEPARA TOON 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, iC?V10. CC) 6an 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: SOCIAL SECURITY #: W NESSES: ADDRESS: 4a PHONE: -7a-D '?l c - & 33e DATE: (o /I It U Revised 1/02 Form #9900-0008 J a I 1 S' .3z`?u ?-a h E lear?1a ?? ; PL 337Y5 File Name: Employee Separation Pay Pref Item # 5 Page 6 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM I, -ECG nG- t_VeincAe/5o11) do hereby apply for retirement under the City of Clearwater General Employees' Pension Plan. Job Classification:' Q)' C? _(?N?oi\,9_ ec l r) i'LINCtVI Sex: M 0 Department: 01 + e Division: Benefits Date: _ t a 4 fS9. Date of Hire: Date of Birth: (0 15 /4 C1. Resignation Date: 71 '-1 a 0- Spouse's Name: h a W)r>; v1 to r14 fFC) /1 Sex: ® F Spouse's Date of Birth: 0- lax e S? 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?v 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 # 5 Page 7 of 138 Option 9 - 100% joint & Survivor Ann City - (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: Employee's Signature: Date: 01 ( 116 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 foregoing n strument was acknowledgedbefore me this COUNTY OF PINELLAS (I 1 I) ii ( 0 by Gci/?GCYI? e?SG who is personally known to me or who has provided as identif' tion nd who di /did no_ a 'oath. Notary Public (Signatu ,, ) k p,t d ( L _ F-y r Name of Notary Printed My Commission expTv vt1,tC-Sr:r., P C:q I) F-D it h i.. .. Rev. 4108 Form #9900-0009 File Name: Pension Entitlement Option Form Item # 5 Page 8 of 138 II Estimated Pension Worksheet II Diana Henderson LAST DATE PAID: 8/31/2010 BENEFITS DATE 12/4/1989 CREDITED SERVICE 20.7417 4pz,t; lcx ???'?-? ye? Signature: Date: - / I GROSS CALENDAR PENSION YEAR EARNINGS 2004 $40,659.60 2006 $41,915.19 2007 $44,371.02 2008 $46,419.43 2009 $47,274.54 $220,639.78 (5 Year Total) 5/ $44,127.96 (Yearly Avg) 12/ $3,677.33 (Monthly Avg) x 0.0275 (Benefit Rate) x 20.7417 (Yrs of Service) $2,097.53 (Est Mtly Pension) Item # 5 Page 9 of 138 C/TY OF CLEARvvATER EMPLOYEES' SERA RAT/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 hour lirS 11011,14 6 an employee pension benefits under the City's Employees' Pension Plan. of 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 3qo, o 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: SOCIAL SECURITY #: WITNESSES: ADDRESS: S U S I I' P-CJOWICA LGv1 F &&kc? X ?4w ?Jew par? AJW, rL -? 1"s-;i PHONE: DATE: v Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 5 Page 10 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM I, `,?q (A t- ics 1 10-14 01 n do hereby apply for retirement under the City of Clearwater General Employees' Pension Plan. Job Classificaiic>li: ??r K S JC Irv `,CC :TfC_kn1 &G(e) L Sex: (3 F Department: t rks i ?creQ'I4ov) Division: Benefits Date: 141s-110 Date of Hire: I TM 0 Date of Birth: 7 /Y I 8 Resignation Date: 3U o Spouse's Name: 1-0 ?.1 Sex: M F, Spouse's Date of Birth:-/ / ISO 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 # 5 Page 11 of 138 Option 6 - 10% joint x, Survivor Anne 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 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 #: S Description: 7 S 'Td 70C/7-f c S V vc/+'uc? Z4r7 ? My design ed ben claryjs: 1.13 ISO Name: oAn b,'l-? Date of Birth: 11 Sex M(9 Social Security Number: Phone Number: 7 a c/?/- S I ?/ Address: SO S i ? ect-d owlark Lahc-. A)44 PPJ . ?2,LA P Y , rL 3 VC 5-3 nature: Date: (o /Y // d STATE OF FLORIDA The foreg ing instrument was acknowledged before me this COUNTY OF PINELLAS c? by CA cfdeS iPa i;4 who is personally knwn to me or who has provided as idenrflo end who t t e an oath. (Signatu e) Notary Public )Cr I Name of Notary Printed My Commission expire Al E UP FLORMA Deborah L. Ford Commission # DD763426 Expires: MAY 15, 2012 30.*IDED THRU ATI.&14MC BOA-DWO C0„ WC, Rev. 4/08 Form #9900-0009 File Name: Pension Entitlement Option Form Item # 5 Page 12 of 138 Estimated Pension Worksheet Charles Maybin LAST DATE PAID: 7/4/2010 BENEFITS DATE 1/15/1990 CREDITED SERVICE 20.4694 Signature: '- Date: (D N U GROSS CALENDAR PENSION YEAR EARNINGS 2005 $41,085.35 2006 $42,600.13 2007 $43,581.20 2008 $44,708.62 2009 $45,383.21 $217,358.51 (5 Year Total) 5/ $43,471.70 (Yearly Avg) 12/ $3,622.64 (Monthly Avg) x 0.0275 (Benefit Rate) x 20.4694 (Yrs of Service) $2,039.22 (Est Mtly Pension) Item # 5 Page 13 of 138 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors ESTIMATE Employee Name: Charles Maybin Employee Date of Birth: 7 4 1948 Marital Status: m Spouse Date of Birth: 11 13 1950 Beneficiary Date of Birth: 11 13 1950 Benefit Commencement Date : 8 1 2010 Estimated Monthly Normal Retirement Benefit: $2,039.22 Option 1 Option 2 Option 3 Option 4 Option 5 Option 6 04-Jun-10 sm clract01 Version: 1-4-96 Actuarial Equivalent Adjustment Factors: Normal Form 1.00000 Life Annuity 1.12572 10 Year Certain 1.08983 50% J&S 75% J&S 1.04371 1.00703 100% J&S ESTIMATE 0.97284 Estimated Monthly Benefit $2,039.22 $2,295.59 $2,222.41 $2,128.36 $2,053.55 $1,983.83 Item # 5 Page 14 of 138 C/7 "Y OF CLEARKIATER EMPLOYEES' SEPARAT/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, ICV 61Q 1/7 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 Lump Sum ld' '5 . vacation S76-03, sick floaters bonus hours 2 S" 0 bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. W TNESSES: 11??? Revised 1/02 Form #9900-0008 ` R EMPLOYEE'S SIGNATURE: ?K-????? SOCIAL SECURITY #: ADDRESS -153&- C, UfC ,S- . 1 yea CuJcJ e!, r-L 3 3.75 PHONE: -717/ y--a' 3-?- er DATE: (,I(-(11o File Name: Employee Separation Pay Pref Item # 5 Page 15 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM I, _ >_a v) CY r0_., t+- C ? "" CL n . do hereby apply for retirement under the City of Clearwater General Employees' Pension Plan. Job ClassificafiQ?: ??A Vl ki e / Sex: M 0 Department: N 4 ?? ? l e v e l o men-" Division: Benefits Date: L Date of Hire: _ I a7 C Date of Birth: 7 as S Resignation Date: 7 30 / U Spouse's Name: ?chv7 I'tC rMQlq Spouse's Date of Birth /! a3 Sex: M,i 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 Annnit? 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 - 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 # 5 Page 16 of 138 Option e - 100% joint R Survivor annul b ? _ (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: /%, C? ?- Date: d 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 ing ' strument was acknowledged before m this COUNTY OF PINELLAS ? U by ??c? n?YGL P?'/!')Grt who is personally known to me or who has provided as iden ! atio and who di /di Notary Public // (Signs re) IUD Name of Notary Printed My Commissimft;-PX-OPM C STATE nFELnRTDA Deborah L. Ford Commission # DD763426 Expires: MAY 15, 2012 . ;uUD THRU Xn.&N-"nC BO\'DING CO., INC. Rev. 4/08 Form #9900-0009 File Name: Pension Entitlement Option Form Item # 5 Page 17 of 138 II Estimated Pension Worksheet II Sandra Herman LAST DATE PAID: 7/31/2010 BENEFITS DATE 1/27/1986 CREDITED SERVICE 24.5111 Signature: [",*? vj? Date: C, /!z /Z o GROSS CALENDAR PENSION YEAR EARNINGS 2004 $70,870.49 2005 $71,051.70 2006 $73,893.76 2007 $68,066.04 2009 $68,777.28 $352,659.27 (5 Year Total) 5/ $70,531.85 (Yearly Avg) 12/ $5,877.65 (Monthly Avg) x 0.0275 (Benefit Rate) x 24.5111 (Yrs of Service) $3,961.86 (Est Mtly Pension) Item # 5 Page 18 of 138 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors ESTIMATE 04-Jun-10 sm clract01 Version: Employee Name: Sandra Herman 1-4-96 Employee Date of Birth: 7 22 1952 Marital Status: m Spouse Date of Birth: 11 26 1953 Beneficiary Date of Birth: 11 26 1953 Benefit Commencement Date : 8 1 2010 Estimated Monthly Normal Reti rement Benefit: $3,961.86 Actuarial Equivalent Adjustment Factors: Option 1 Normal Form 1.00000 Option 2 Life Annuity 1.09786 Option 3 10 Year Certain 1.07607 Option 4 50% J&S 1.03458 Option 5 75% J&S 1.00560 Option 6 100% J&S 0.97820 ESTIMATE Estimated Monthly Benefit $3,961.86 $4,349.57 $4,263.24 $4,098.87 $3,984.06 $3,875.50 Item # 5 Page 19 of 138 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. , an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. EMPL OYEES' SEPARA T/ON PA Y PREFERENCES C{T Y OF CLEARb"?ATER 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 CZ yd sick _ /!;-() floaters - `?S bonus hours Lump Sum Y k, 11 vacation I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. EMPLOYEE'S SIGNATURE: (2 -e?j SOCIAL SECURITY #: - ///? WITNESSES: ADDRESS: O '`71SI 14uc, k), tom, eltas a? {-?. 33 7rJ'? PHONE: oZ? I SY ?°- t?y?7 DATE: A(/ 0 Revised 1/02 Form 119900-0008 File Name: Employee Separation Pay Pref Item # 5 Page 20 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM 1, !> rVevi of Clearwater General Job Classificz: Department: _ Benefits Date: Date of Birth: Spouse's Name: Spouse's Date of Birth: Sex: M 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 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 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 tir 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 # 5 yev her- loyees' Pension Plan. IV4- do hereby apply for retirement under the City Division: Date of Hire: Resignation Date: Page 21 of 138 Option b - aQ0 l„ joint & Survivor Ann city - (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 #: _L 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 Option #: 2 Description: Life Annijity Employee's Signature: Date: _ b- 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 forego ng ?Is tr ument was knowledged before me this COUNTY OF PINELLAS (F ?( U by ICUev-(iLy b y'ler • who is personally known to me or who has provided as ide tifica 'on and wh dirdi t 4Wth. j Q ?r 6(Signatur Notary Public ?/V? .. Name of Notary Printed My Commission expires: STATE OFFLpRIDA Deborah L. Ford Coumission # DD763426 Fxpires: MAY 15, 2012 ?ONDED THRU ATLILYnC BONDING CO, INC. Rev. 4/08 Form #9900-0009 File Name: Pension Entitlement Option Form Item # 5 Page 22 of 138 Estimated Pension Worksheet Beverly Verner LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 6/4/2010 11/4/1985 24.5833 Prepared by: Deborah Ford Date: 6/4/10 GROSS CALENDAR PENSION YEAR EARNINGS 2005 $32,194.05 2006 $34,232.19 2007 $35,795.85 2008 $36,163.60 2009 $37,213.91 $175,599.60 (5 Year Total) 5/ $35,119.92 (Yearly Avg) 12/ $2,926.66 (Monthly Avg) x 0.0275 (Benefit Rate) x 24.5833 (Yrs of Service) $1,978.54 (Est Mtly Pension) Item # 5 Page 23 of 138 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors 04-Jun-10 sm ESTIMATE clract01 Version: Employee Name: Beverly Verner 1-4-96 Employee Date of Birth: 5 20 1946 Marital Status: s Spouse Date of Birth: Beneficiary Date of Birth: Benefit Commencement Date : 7 1 2010 Estimated Monthly Normal Retirement Benefit: $1,978.54 Actuarial Equivalent Adjustment Factors: Option 1 Normal Form 1.00000 Option 2 Life Annuity 1.00000 Option 3 10 Year Certain 0.95911 Option 4 50% J&S #DIV/0! Option 5 75% J&S #DIV/0! Option 6 100% J&S #DIV/0! ESTIMATE Estimated Monthly Benefit $1,978.54 $1,978.54 $1,897.64 #DIV/0! #DIV/0! #DIV/0! Item # 5 Page 24 of 138 C/TY OF CLEARIf'JATER 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, ?u 1?? ?Ct,blyv'1SKI 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 t Lump Sum 3 5- vacation sick floaters bonus hours vacation i DL G,-11 sick -7.5 floaters tea, -5 bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. EMPLOYEE'S SIGNATURE: ?J SOCIAL SECURITY #: ' ' • - - W TNESSES: ADDRESS: 44k-ed- Y ??a L 0 C M rrp n? M 14A V ho V, ?- L PHONE: 7 o?L-7/ -71'`7- SV6 0 Revised 1/02 Form #9900-0008 DATE: (P /"f 1 U File Name: Employee Separation Pay Pref Item # 5 Page 25 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM I, V C",t/,6- \JR 01201 y of Clearwater General Employees' aPension Plan. Date of Birth: /0/_1 do hereby apply for retirement under the City Job Classificaf n: So /1 d wCe4c ' Department: + U.4e ??ev Benefits Date: a -a e ?." Division: _ Date of Hire: Resignation Date: / Spouse's Name: jeo!jUS 1 a u \_Ja DlyriS'k_i? Sexg F Spouse's Date of Birth: 9IAq j?,- The type of pension for which I am applying is (check only one): k 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 # 5 Page 26 of 138 Option b - 100% 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 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. KI 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 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 COUNTY OF PINELLAS Rev_ 4108 Form #9900-0009 The foregoin ins rument was acknowledged before me this y /U by J46/U17Sk i who is personally known to me or who has provided as identification and who did/did not take an oath. (Signa?ure) Notary Public \ y'??G ?? ,? /?? Name of Notary Printed My Commission expires: File Name: Pension Entitlement Option Form Item # 5 Page 27 of 138 II Estimated Pension Worksheet II Julia Jablonski LAST DATE PAID: 7/31/2010 BENEFITS DATE 2/22/1988 CREDITED SERVICE 22.4417 Signature: J Date: (, V GROSS CALENDAR PENSION YEAR EARNINGS 2005 $47,265.65 2006 $49,148.85 2007 $51,356.15 2008 $56,329.24 2009 $58,214.38 $262,314.27 (5 Year Total) 5/ $52,462.85 (Yearly Avg) 12/ $4,371.90 (Monthly Avg) x 0.0275 (Benefit Rate) x 22.4417 (Yrs of Service) $2,698.10 (Est Mtly Pension) Item # 5 Page 28 of 138 C/T Y OF CLEAR'IIATER 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. 1, a,r?- _ 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 # -.2- and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out q y 0 ' 0 vacation o2 I ' Osick floaters Jo-10'0 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: SOCIAL SECURITY #: WI NESSES: ADDRESS: V- PHONE: DATE: 01110 Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 5 Page 29 of 138?T CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM of Clearwater General Employees' Job Classificaft Department: ° Benefits Date: Date of Birth: sion Plan. do hereby apply for retirement under the City r. Division: _ Date of Hire: Resignation Date: Spouse's Name. 't'? ?? ??? aVT Sex: MG Spouse's Date of Birth:Y 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 # 5 HlldGi III iei nT Page 30 of 138 Option 6 - 100% .ioint & ti +rvivor ann rife - (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: If taking Option 3.4. 5. or 6 fill in beneficiarv information and sign below: Option Description: 1o d°a ?`n-? ti Jv?y + vO/ nv, U+` My des' „ at d bpn I ry is: Name: Q c.c- w + ,? uvt Date of Birth: 9 S Sex MO Social Security Number: Phone Number: 1 -7 ?4- L, Address: c? to U l-.-)o r Qx.? J f r CA ?,_u0.? fL 'E-7C, 3 _3 ? S5 Employee's Signature: Date: d STATE OF FLORIDA The fore oin instrument was acknowledged before me this COUNTY OF PINELLAS 0 by C y?WL!,; qi, ? who is personally known to me or who has provided as id?tifica 'on and w did/ i of ke an oath. Notary Public (Si atur d r r Name of Notary Printed My Commission expires: NOTARY PUBLIC-STATE OF FLORIDA Deborah L. Ford ``'fi'r :Commission # DD763426 Rev. 4108 ,, - Expires: MAY 15, 2012 Form #9900-0009 BONDED TxxU ATt ANTIC BONDING co., DX. File Name: Pension Entitlement Option Form Item # 5 Page 31 of 138 II Estimated Pension Worksheet II Carl Swigart LAST DATE PAID: 11/5/2010 BENEFITS DATE 2/12/1981 CREDITED SERVICE 29.7306 Signature: &4&4 VV4 Date: i a GROSS CALENDAR PENSION YEAR EARNINGS 2005 $50,591.31 2006 $53,536.11 2007 $54,306.59 2008 $55,219.11 2009 $58,407.73 $272,060.85 (5 Year Total) 5/ $54,412.17 (Yearly Avg) 12/ $4,534.35 (Monthly Avg) x 0.0275 (Benefit Rate) x 29.7306 (Yrs of Service) $3,707.24 '(Est Mtly Pension) Item # 5 Page 32 of 138 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors 01-Jun-10 sm ESTIMATE c1ract01 Version: Employee Name: Carl Swigart 1-4-96 Employee Date of Birth: 11 5 1955 Marital Status: M Spouse Date of Birth: 9 28 1959 Beneficiary Date of Birth: 9 28 1959 Benefit Commencement Date : 12 1 2010 Estimated Monthly Normal Reti rement Benefit: $3,707.24 Actuarial Equivalent Adjustment Factors: Option 1 J&S Annuity 1.00000 Option 2 Life Annuity 1.09612 Option 3 10 Year Certain 1.08031 Option 4 50% J&S 1.03400 Option 5 75% J&S 1.00551 Option 6 100% J&S 0.97855 ESTIMATE Estimated Monthly Benefit $3,707.24 $4,063.56 $4,004.97 $3,833.29 $3,727.67 $3,627.71 Item # 5 Page 33 of 138 CITY OF CLEARWA TER 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. 1, 11S0t7 ?d?NSdV1 villmil 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 floaters Y" to ® bonus hours Lump Sum y Y, vacation S71'16 sick 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 MESSES: ADDRESS: 00 Sv ??-+ ??• I f La r q o? ?L. X 3 7 7 /. PHONE: ?? - S yS DATE: Col U ?l d Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 5 Page 34 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM 1, A I I SO 01 -j 0, *7 r? S a k? of Clearwater General Employees' Pension Plan. Job Classifica Department: _ Benefits Date: Date of Birth: do hereby apply for retirement under the City Division: Date of Hire: _ Resignation Date Spouse's Name: (? regoy: A • i t hgrOlsOvr Sex: Q F Spouse's Date of Birth: Ff 1 br'W 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 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. [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 beneficiarys 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% Join & Survivor Anni lit-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 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 K 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 # 5 Page 35 of 138 Option 6 - 1100% joint & Survivor Annid 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 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: X Date: If taking 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 forego'ng instrument was acknowledged before me this COUNTY OF PINELLAS by A/1 - o o OA .1-7 S G h who is personally known to me or who has provided as ider0ification and who an oath. Notary Public L.-- 1-0,-g , Name of Notary Printed NOTARY PUBLIC-STATE OF FLORIDA My Commission expires:.......... :WgbQtRb L- Ford CcrjTni.ssion # DD763426 Expires: MAY 15, 2012 BONDED THRU ATLANTIC BONDING CO., INC. Rev. 4/08 Form #9900-0009 File Name: Pension Entitlement Option Form Item # 5 Page 36 of 138 Estimated Pension Worksheet Alison Johnson LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 4/30/2010 2/2/1987 23.2444 Signature: Date: / G / d GROSS CALENDAR PENSION YEAR EARNINGS 2005 $39,844.73 2006 $40,738.17 2007 $41,435.26 2008 $42,946.14 2009 $43,140.17 $208,104.47 (5 Year Total) 5/ $41,620.89 (Yearly Avg) 12/ $3,468.41 (Monthly Avg) x 0.0275 (Benefit Rate) x 23.2444 (Yrs of Service) $2,217.08 (Est Mtly Pension) Item # 5 Page 37 of 138 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors 10-Jun-10 sm ESTIMATE clract01 Version: Employee Name: Alison Johnson 1-4-96 Employee Date of Birth: 4 8 1953 Marital Status: M Spouse Date of Birth: 8 18 1948 Beneficiary Date of Birth: 8 18 1948 Benefit Commencement Date : 5 1 2010 Estimated Monthly Normal Retirement Benefit: $2,217.08 Actuarial Equivalent Adjustment Factors: Option 1 J&S Annuity 1.00000 Option 2 Life Annuity 1.06710 Option 3 10 Year Certain 1.04813 Option 4 Option 5 Option 6 50% J&S 75% J&S 100% J&S ESTIMATE 1.02415 1.00395 0.98452 Estimated Monthly Benefit $2,217.08 $2,365.85 $2,323.78 $2,270.62 $2,225.83 $2,182.77 Item # 5 Page 38 of 138 CITY OF CLEARWATER 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. soft- I, ?r 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 3 , `? 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: SOCIAL SECURITY #: vmia ADDRESS: Nu oIaV) N)r S(t) r4a, FL v PHONE: -2x'01 DATE: &?/ Revised 1/02 Form #/9900-0008 File Name: Employee Separation Pay Pref Item # 5 Page 39 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM 1, %_? Q knor moo_ N4 uu0 ev do hereby apply for retirement under the City of Clearwater General Employees' Pension Plan. Job Classificatio :l„ U34PIne - ?rrO GC Aouy) ?/ ?n Sex: M Department: by Mir ? ?'c Division! Benefits Date: 3 b Date of Hire: 3 a 6 ?? Date of Birth: a3 y /ZUj signaDilate: -23O /o Spouse's Name: r'C? a -d Sex: © 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 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 # 5 Page 40 of 138 Option 6 - 1100% .mint P. q,-??..r 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 Employee's Signature: X Date: 62 h y k 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 or6_fill in_be_n_eficiarv 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 foregoing instrument was a h is COUNTY OF PINELLAS ?, f { 11 by h?R Y ( who i s personally known to me or who has provided as iden?and who did/ i? d rypt k an oath. (??lJ _n gnatu ) Notary Public Name of Notary Printed My CommissionleXRTMSUB Deborah L. Ford rh Commission # DD763-126 '- Expires: MAY 15, 2012 BONDED THRU A`f1,AN` IP Jw1N,) 3JE ca. LNC. Rev. 4/08 Form #9900-0009 File Name: Pension Entitlement Option Form Item # 5 Page 41 of 138 II Estimated Pension Worksheet II Sandra Howard LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 7/30/2010 GROSS CALENDAR PENSION YEAR EARNINGS 2006 $37,792.54 2007 $37,708.58 2008 $38,114.61 2009 $39,193.15 2010 $39,193.15 3/26/1984 26.3444 Signature: Date: Y /v $192,002.03 (5 Year Total) 5/ $38,400.41 (Yearly Avg) 12/ $3,200.03 (Monthly Avg) x 0.0275 (Benefit Rate) x 26.3444 (Yrs of Service) $2,318.33 (Est Mtly Pension) Item # 5 Page 42 of 138 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, K Qke- + 10. 0') ct 1 0 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 Ily 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 -7c2gQ- vacation 44-53, sick floaters 5- © 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 #: WFNESSES: ADDRESS: _ PHONE: Revised 1/02 Form #9900-0008 DATE: File Name: Employee Separation Pay Pref Item # 5 Page 43 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM I, IS eLf-L / I la 4L_ ya /I ce I oti of Clearwater General Employees' Pension Plan. Job Classification. Department: Benefits Date: _ Date of Birth: 1/d l l Gam- - / i Ce. fl Spouse's Name: Spouse's Date of Birth: do hereby apply for retirement under the City r.?n4`?an 1 CG{? r1,'c! 4 h Sex: M AM 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 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 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. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% 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 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)] tem 4 5 Division: Date of Hire: // d Resignation Date: $ ? 3 It 0 Page 44 of 138 Option 6 -'i00% joint & Survivor Ann Ii 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 #: I Descr' n: _Joint and Survivor Annuity Employee's Signature: orlt-, Date: (0 / y 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 taking 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 foregoing instrument was acknowled n d bef e me this COUNTY OF PINELLAS /? e j? [ by ?jV? ''tom who is personally known to me or who has provided as identif? ion and who?d?d riot to an th. /lJ signat e) //,?(? Notary Public ?? - r-0 fO( Name of Notary Printed My Comm iss gbli,M Deborah L. Ford Commission #DD763426 Expires: MAY 15, 2012 Rev. 4/08 BONDED THRU ATLANTIC BONDING CO., INC. Form #9900-0009 File Name: Pension Entitlement Option Form Item # 5 Page 45 of 138 11 Estimated Pension Worksheet Kate MacDonald LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 8/13/2010 11/10/1986 23.7583 1 Signature: Date: L / `T / U GROSS CALENDAR PENSION YEAR EARNINGS 2005 $36,367.21 2006 $40,317.94 2007 $42,481.88 2008 $40,913.68 2009 $41,191.03 $201,271.74 (5 Year Total) 5/ $40,254.35 (Yearly Avg) 12/ $3,354.53 (Monthly Avg) x 0.0275 (Benefit Rate) x 23.7583 (Yrs of Service) $2,191.70 (Est Mtly Pension) Item # 5 Page 46 of 138 CITY OF CLEARWATER 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 ?atVY1 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 (10/0 vacation Yk?W sick a.& floaters 16 bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. EMPLOYEE'S SIGNATURE: -1? ;; SOCIAL SECURITY #: _ WI NESSES: ADDRESS: I&A-VLca ty- 0V Revised 1/02 Form //9900-0008 cio)- v Qu ev ? rOdte - (2,1eck?wAev. ?3-7SS- PHONE:,.-7d--7 ' 1 4-7 0 ?. DATE: &1i-7116 File Name: Employee Separation Pay Pref Item # 5 Page 47 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM 1, Lu" I I ),Ccm EQ r42C h) 1 0( do hereby apply for retirement under the City of Clearwater General Employees' Pension Plan. Job Classificatio w 1)'C. U h 41rs CC?J`ic/A" -?T Sex:0 F Department: d G ? r Division: Benefits Date: S 3 S Date of Hire: d3 Date of Birth: !V 3 Resignation Date: d 7 / 6 - 11-11 C_ Spouse's Name: Spouse's Date of Birth: Axf Sex: M 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 & 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 # 5 Page 48 of 138 Option 6 - 100% .loin' & Survivor ,4nn fify - (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: D 2,f Z2 (oO l1711 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 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 for goin instrument was acknowledged before m this COUNTY OF PINELLAS // j? /J 7 Q, b- 1/!a"Ctvn /,",-/I ?CC who is personally known to me or who has provided as i tifi tion an w?id/ i of take an oath. Notary Public ur j (Synat? 'r LL Name of Notary Printed My Commission expires: NOTARY ;5'ubue-STA`PE OF FLORIDA Deborah L. Ford Commission # DD763426 Rev. 4108 ' Expires: MAY 15, 2012 Form #9900-0009 110NDRa THRU Pi e?V??FW KV8nNtitlement Option Form Item # 5 Page 49 of 138 1 Estimated Pension Worksheet 11 William Fairchild LAST DATE PAID: 8/27/2010 BENEFITS DATE 5/23/1988 CREDITED SERVICE 22.2611 Signature: Date: G? GROSS CALENDAR PENSION YEAR EARNINGS 2004 $46,901.25 2005 $46,761.38 2007 $49,447.42 2008 $48,636.92 2009 $46,723.96 $238,470.93 (5 Year Total) 5/ $47,694.19 (Yearly Avg) 12/ $3,974.52 (Monthly Avg) x 0.0275 (Benefit Rate) x 22.2611 (Yrs of Service) $2,433.12 (Est Mtly Pension) Item # 5 Page 50 of 138 CITY OF CLEARWA TER EMPLO 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. 1, - ??? ? I ?'t? m .f I?. ?y? Zyr?C: r). 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 vacation -74yU. C) 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: of U r S-4 - Revised 1/02 Form #9900-0008 e` c, L. jct rl 3R' 76 0 PHONE: S 3i-70V7 DATE: File Name: Employee Separation Pay Pref Item # 5 Page 51 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM 1, l?< 4!!?, /J n;l -mil L stn of Clearwater General Employees' Pension Plan. Job Classification: Department: ILA- Benefits Date: Date of Birth: do hereby apply for retirement under the City Division: _ Date of Hire: Resignation Date: Sex: U . F Spouse's Name: !,???J v? l?. xl Sex: M Spouse's Date of Birth: 9???, /?? 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-iob-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 (42 #6) shall be computed to be the Actuarial Equivalent of the normal benefit. Option 1 -.1nint and Gurviver 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 (e) (3)] Option - Life Annuity -, r The Participant receives his/her pension as long as he/she lives. Upon the death of the Part icipant, benefits cease. [Section 2.398 (b) (2) (A) (i)] Option 3 - 10 Y ar Certain R Life Annuity, - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies beforQ 120 monthly payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary, or the estate if his/her beneficiary is not alive. [Section 2.398 (b) (2) (A) (ii)] Option 4 - 50% 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 50% of the pension for the rest of their 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) (iii)] Option 5 - 75% Joint P. Survivor Anne t* - (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 their 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) (iii)] Item # 5 Page 52 of 138 Option 6 1 n0% Joint & Giirvivor 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 their 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) (iii)] 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: 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* 9 Description: LIP Annuity ha Date: Employee's Signature: Option #: My designated beneficiary is: Name: Social Security Number: - Address: re: Description: . ioint and Si miivor Annuity Description: Date of Birth: Sex MF Phone Number: Date: STATE OF FLORIDA The fore oin instrument wascknowled ed b fojr? me this COUNTY OF PINELLAS CA, (7 ?? (J by 07i 4 who is personally known to me or who has provided as idX ific ion and ho d of ake a oath. Notary Public drt?-/1 L -t Name of Notary Printed My Commission expires: New 2/96 Form #9900-0009 File Name: Pension Entitlement Option Form Item # 5 Page 53 of 138 II Estimated Pension Worksheet II William Kunzman LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 7/30/2010 GROSS CALENDAR PENSION YEAR EARNINGS 2004 $41,209.51 2005 $40,326.99 2006 $41,446.72 2008 $39,976.45 3/31/1987 23.3333 Signature: Date: 'p ((-1((o 2009 $39,608.61 $202,568.28 (5 Year Total) 5/ $40,513.66 (Yearly Avg) 12/ $3,376.14 (Monthly Avg) x 0.0275 (Benefit Rate) x 23.3333 (Yrs of Service) $2,166.36 (Est Mtly Pension) Item # 5 Page 54 of 138 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors ESTIMATE Employee Name: William Kunzman Employee Date of Birth: 6 21 1944 Marital Status: m Spouse Date of Birth: 9 26 1954 Beneficiary Date of Birth: 9 26 1954 Benefit Commencement Date : 8 1 2010 17-Jun-10 sm clract01 Version: 1-4-96 Estimated Monthly Normal Retirement Benefit: $2,166.36 Actuarial Equivalent Adjustment Factors: Option 1 Normal Form 1.00000 Option 2 Life Annuity 1.22245 Option 3 10 Year Certain 1.15833 Option 4 50% J&S 1.07324 Option 5 75% J&S 1.01150 Option 6 100% J&S 0.95649 ESTIMATE Estimated Monthly Benefit $2,166.36 $2,648.26 $2,509.36 $2,325.02 $2,191.28 $2,072.10 Item # 5 Page 55 of 138 CITY OF CLEARWA TER 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, ?-? eil2irlCt S S 0 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 013=11 vacation EI L sick floaters bonus hours a o, 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: 'Al SOCIAL SECURITY #: WI NESSES: ADDRESS: 121- 3 0 0 provy?en&dz r ??d r PHONE: -7 ?1 I -73 q---,-j0 OkDATE: Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 5 Page 56 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM I, J'4-CU ek1 Q--,r0-SS O of Clearwater General Employees' Pension Plan. Job Classification: Department: 0.r ne ?- SS Benefits Date: ( 15, Date of Birth: f © i_ do hereby apply for retirement under the City -? pp rcxcAes WO/ Y Sex: 0 F Division: Date of Hire:. i a 7 .?? Resignation Date: S ff7 / U 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)] - (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 # 5 Page 57 of 138 Option 6 - 100% joint & Survivor Ann iibL -(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 es ' n: Joint and Survivor Annuity Employee's Signature: A Date: (-A-7/10 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 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 COUNTY OF PINELLAS Rev. 4/08 Form #9900-0009 The forego g instrument was acknowledged before me this / 7 /d' by S_-Cvev'x ?YC??SU personally known to me or who has provided who is as iden nationon an iP/o? take an oath. Notary Public (Sign ture) D -`J d'? ? "" 04 Name of Notary Printed My Commission e ire Deborah L. Ford Commission #DD763426 Expires: MAY 15, 2012 ri(i\DED THRU ATLANTIC B014DING CO., INC. File Name: Pension Entitlement Option Form Item # 5 Page 58 of 138 1 Estimated Pension Worksheet II Steve Grasso LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 8/27/2010 1/5/1985 25.6444 Signature: Date: (a 1 r7 10 GROSS CALENDAR PENSION YEAR EARNINGS 2004 $13,088.88 estimated 8 pay periods of 2005 2006 $46,646.15 2007 $46,826.65 2008 $47,264.71 2009 $48,360.88 2010 $34,256.67 estimated 18 pay periods of 2010 $236,443.94 (5 Year Total) 5/ $47,288.79 (Yearly Avg) 12/ $3,940.73 (Monthly Avg) x 0.0275 (Benefit Rate) x 25.6444 (Yrs of Service) $2,779.09 (Est Mtly Pension) Item # 5 Page 59 of 138 CITY OF CLEARWA TER EMPL O VEES' SEPARA TION PA V 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?' ?? erg 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 yC'' vacation zA 1 S' 19 sick floaters 1020' © bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. , 1 P EMPLOYEE'S SIGNATURE: SOCIAL SECURITY #: WI NESSES: ADDRESS: /014 o"? ?aL" I ee-V% PHONE: -7.1-71 quo M-' V VT DATE: h t4 h 0 Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 5 Page 60 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM I, Jc?c,K r,IITMley, of Clearwater General Employees' Pension Plan. Job Classifica Department: _ Benefits Date: Date of Birth: Spouse's Name: Spouse's Date of Birth: 7 do hereby apply for retirement under the City Division: _ Date of Hire: Resignation Date: iS n I Pr- Sex: M lrJ 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 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 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 4 5 Page 61 of 138 Option 6 - i000/. joint & Survivor Ann tity - (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: 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: it taking Vptlon 3, 4, 5, or 6 fill in beneficiar Option #: Description: /)4 c S 'u My designa?tiel _beneficiY is: Name: Ul,'Z Date of Birth: Sex MO Social Security Number: Phone Number: ?o17 ?? r- t/0 -;7 Address: Description: Joint and Survivor Ann city dy l W o Employee's Signature: ylk", 7 Date: lO by, o STATE OF FLORIDA The forego' g in)110 rument was acknowled e!d b fore me this COUNTY OF PINELLAS by ??? ' who is personally known to me or who has provided as identification and who did/did not take an oath. a(Signature) 671a r-0 W Notary Public Name of Notary Printed My Commission expires: TARYPUBLIC-STATEOFFIOR A ora L. Ford _`- Commission #DD763426 Expires: MAY 15 2012 z30,N'DED THRU ATLANTIC MIDING Co., CvC. Rev. 4/08 Form #9900-0009 File Name: Pension Entitlement Option Form Item # 5 Page 62 of 138 Estimated Pension Worksheet Richard Mishler LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 7/30/2010 6/17/1985 25.1194 Signature: Date: C GROSS CALENDAR PENSION YEAR EARNINGS 2004 $48,426.49 2006 $50,601.01 2007 $58,047.23 2008 $58,250.41 2009 $62,751.52 $278,076.66 (5 Year Total) 5/ $55,615.33 (Yearly Avg) 12/ $4,634.61 (Monthly Avg) x 0.0275 (Benefit Rate) x 25.1194 (Yrs of Service) $3,201.52 (Est Mtly Pension) Item # 5 Page 63 of 138 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors 14-Jun-10 sm ESTIMATE clract01 Version: Employee Name: Richard Mishler 1-4-96 Employee Date of Birth: 11 10 1953 Marital Status: M Spouse Date of Birth: 1 12 1957 Beneficiary Date of Birth: 1 12 1957 Benefit Commencement Date : 8 1 2010 Estimated Monthly Normal Reti rement Benefit: $3,201.52 Actuarial Equivalent Adjustment Factors: Option 1 J&S Annuity 1.00000 Option 2 Life Annuity 1.10214 Option 3 10 Year Certain 1.08254 Option 4 50% J&S 1.03600 Option 5 75% J&S 1.00583 Option 6 100% J&S 0.97736 ESTIMATE Estimated Monthly Benefit $3,201.52 $3,528.51 $3,465.77 $3,316.78 $3,220.17 $3,129.03 Item # 5 Page 64 of 138 CITY OF CLEARWATER EMPL O PEES' 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. 1, - t 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 # f 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 1 qL .59 vacation // / V- It sick floaters bonus hours IOC- -? 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 #: - 11 /I WITNESSES: ADDRESS: -- 3 O $ L USrCxGYOS )Sr - /& ?? ?j sctkc?? FL 9 r PHONE: -7a7 ) 3? ?v --, 10 5 DATE: f I Y//0 Revised 1/02 e e 1( -7X7/Y/7- 7304 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 5 HLCaGflfile11L HUITIDer F Page 65 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM 1, I-G`tT V c/V CL n VjCL V, 1(C ?l do hereby apply for retirement under the City of Clearwater General Employees' Pension Plan. Job Classification: Vh%n ? S ?-rq r-i u,?-' v J+ c-.vt CL e-K Sex: M(? Department: Svc ?•?ma r?.?? e? a tt Division: Benefits Date: k Date of Hire: -7 T, 7 78- Date of Birth: I Z/ X SS Resignation Date: A-7 1 O Spouse's Name: 1?4-- 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 Ann fits( 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 Anni city - (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 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 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 # 5 Page 66 of 138 Option 6 -100% join' F4 Survivor Ann a 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 `' ?- Descriptioonn:s- Joint and Survivor Annuity Employee's Signature: GC/., Date: zl d 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 foregoing instrument was acknowledged before me this COUNTY OF PINELLAS (, //, (i . by R4-),#,o c,-_ (Vgyre,,q who is personally known to me or who has provided as id 'fica on and wh did/d' n t e an oath. Notary Public f (Signature) , p (" rO-A Name of Notary Printed My Commission expires: NOTARY PUBLIC-STATE OF FLOP1?, Deborah L. Fors -Commission 4DD763426 Rev. 4/08 .••' Expires: MAY 15, 2012 BONDED THRU An AYM BOND Form #9900-0009 I"€eAJ@Ae: Pension Entitlement Option Form Item # 5 Page 67 of 138 Estimated Pension Worksheet Patricia Warren LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 8/27/2010 7/17/1978 32.1111 Signature: Date: GROSS CALENDAR PENSION YEAR EARNINGS 2004 $53,831.76 2006 $52,771.27 2007 $53,528.86 2008 $57,683.00 2009 $58,178.12 $275,993.01 (5 Year Total) 5/ $55,198.60 (Yearly Avg) 12/ $4,599.88 (Monthly Avg) x 0.0275 (Benefit Rate) x 32.1111 (Yrs of Service) $4,061.95 (Est Mtly Pension) Item # 5 Page 68 of 138 CITY OF CL 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. 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 ?•0 sick floaters c? bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. EMPLOYEE'S SIGNATURE: LUAA SOCIAL SECURITY #: , W TNESSES: Ad? ADDRESS: o? 3-? W' (I-e? Ly oc) y ?J r = +-fsL 7 -2 d PHONE: _7 a 2 /S<:?' I c1- t IgATE: Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 5 Hnacnmem numoer F- -, Page 69 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM do hereby apply for retirement under the City of Clearwater G ral Employees' Pe n Plan. L Job Classification: ?Ya A 1 it 12u 1 Sex.GM F Department: 'n ee win -division: Benefits Date: Date of Hire: 7 - (o 11-1 Date of Birth: I o S V Resignation Date: 1.40110 Spouse's Name: 611f, 1-7 i Sex: M0 Spouse's Date of Birth: 10 ci S 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 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)] 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 Annuityy, - (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 ffem # 5 HLLa(;nfnenL HUfrrDeTT Page 70 of 138 Option b - 1000/. 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 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.) 1 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 Description: Life Annuity /? Employee's Signature: X + Date: /JS/? 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 nininstrument was knowle ged before e this COUNTY OF PINELLAS by U G ? / who is personally known to me or who has provided aside t'f' tion and who di /did k n oa Notary Public ,, (S' ature) LSD) L Name of Notary Printed My Commission expo FLORIDA Deborah L. Ford =Commission #DD7 3 26 '' Ex Bo. pires: M?iy 15, 2612 Rev. 4/08 iy AT6V-G BOADI ,NS eo., aNP,? Form #9900-0009 File Name: Pension Entitlement Option Form Item # 5 ruidauneiii IIUIIIuei i Page 71 of 138 Estimated Pension Worksheet Douglas King LAST DATE PAID: 7/30/2010 BENEFITS DATE 6/12/1978 CREDITED SERVICE 32.1333 Signature: 4-4? 4V Date: (P /1 d GROSS CALENDAR PENSION YEAR EARNINGS 2004 $43,583.58 2006 $42,940.72 2007 $43,673.64 2008 $44,144.50 2009 $45,383.21 $219,725.65 (5 Year Total) 5/ $43,945.13 (Yearly Avg) 12/ $3,662.09 (Monthly Avg) x 0.0275 (Benefit Rate) x 32.1333 (Yrs of Service) $3,236.07 (Est Mtly Pension) Item # 5 Page 72 of 138 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors ESTIMATE 01-Jun-10 sm clract01 Version: Employee Name: Douglas King 1-4-96 Employee Date of Birth: 10 4 1954 Marital Status: m Spouse Date of Birth: 10 9 1957 Beneficiary Date of Birth: 10 9 1957 Benefit Commencement Date : 6 1 2010 Estimated Monthly Normal Retirement Benefit: $3,236.07 Actuarial Equivalent Adjustment Factors: Option 1 Normal Form 1.00000 Option 2 Life Annuity 1.09705 Option 3 10 Year Certain 1.07951 ;"Option 4 50% J&S 1.03431 Option 5 75% J&S 1.00556 Option 6 100% J&S 0.97836 ESTIMATE Estimated Monthly Benefit .$3,236.07. $3,550.12 $3,493.38 $3,347.10. $3,254.06 $3,166.05 Item # 5 ruidauneiii IIUIIIDUI i Page 73 of 138 CITY OF CLEARWA TER EMPL O PEES' 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, ?? Glf? a ?Yl Ir ?'t'd l? 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 k4 0, 6 vacation ?FsU'C? sick c2c?-S floaters S- I-?- 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: SY? ?' n? mlJt° jlaA?Az 0? - ? el e a rru.)?c-e r I-L 33f7S1- PHONE: -7 2--I /991-?-33 C DATE: f ?! 3 / / v Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 5 Hnacnmem numoer i Page 74 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM i, 111 VIYI u k, C^_ I'u`n i 171-'T7, do hereby apply for retirement under the City of Clearwater General Employees' Pension Plan. / Job Classification: ?? c S S!'C/nG kq.*I d yU4/Ue f. Sex: F ',n c Department: "PI P ne l Division: Benefits Date: -71-7 n, a Date of Hire: 6 Date of Birth: la -3 br Resignation Date: 7 30d Spouse's Name: Lel v/ n e ' ?'?'?i / T'?`'?- Sex: M 7/1 0 4. S 3 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 & LifP_ 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 # 5 Hnacnmenl numDer i Page 75 of 138 Option 6 - 100% joint & S?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 #: 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: Dater Option #: (0 Description: N (/j My desi ated beneficia)-y is: --)l Name: 3u ZQ hn'-' NAM W0 to of Birth: 07 4 53 Sex MO Social Security Number: Address: SO Phone Number I J(-, 727 YI/Lcf3-5° 3 37SS Employee's Signature: X.i Date: 13 ( 0 STATE OF FLORIDA The foreZXstrume nt wasa knowledged befor me this COUNTY OF PINELLAS d by rC?4rtJX r»r ?7??7 who is personally known to me or who has provided as iden?n d who didtot a a 9t,/)- Notary Public bd ?ature) Name of Notary Printed My Commission; Deborah L. Ford `- Commission # DD763426 Expires: MAY 15, 2012 Rev. 4/08 BONDED THRU ATLANTIC BONDING CO., INC. Form #9900-0009 File Name: Pension Entitlement Option Form Item # 5 Attachment number 1 Page 76 of 138 FF? Estimated Pension Worksheet I Richard Hamilton LAST DATE PAID: BENEFITS DATE CREDITED SERVICE Prepared by: Date: CALENDAR YEAR 7/30/2010 2005 7/7/1975 2006 35.0639 2007 2008 2009 5/ 12/ x x Deborah Ford 6/7/10 GROSS PENSION EARNINGS $55,133.14 $57,329.88 $59,614.05 $61,973.46 $63,946.16 $297,996.69 (5 Year Total) $59,599.34 (Yearly Avg) $4,966.61 (Monthly Avg) 0.0275 (Benefit Rate) 35.0639 (Yrs of Service) $4,789.09 (Est Mtly Pension) Item # 5 HLCaU111T1e11L HUITIDer I Page 77 of 138 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors 07-Jun-10 sm ESTIMATE clract01 Version: Employee Name: Richard Hamilton 1-4-96 Employee Date of Birth: 12 3 1948 Marital Status: m Spouse Date of Birth: 7 26 1953 Beneficiary Date of Birth: 7 26 1953 Benefit Commencement Date : 8 1 2010 Estimated Monthly Normal Retirement Benefit: $4,789.09 Actuarial Equivalent Adjustment Factors: Option 1 Normal Form 1.00000 Option 2 Life Annuity 1.14517 Option 3 10 Year Certain 1.10867 Option 4 50% J&S 1.04991 Option 5 75% J&S 1.00799 Option 6 100% J&S 0.96928 ESTIMATE Estimated Monthly Benefit $4,789.09 $5,484.34 $5,309.50 $5,028.12 $4,827.34 $4,641.97 Item # 5 Page 78 of 138 CITY OF CLEAR INATER EMPLOYEES' 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. 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 o7-)3A-LA- sick d, S floaters I10?° S bonus hours I understand that my preference cannot be changed once this form nisined and that my decision is irrevocable. EMPLOYEE'S SIGNATURE: SOCIAL SECURITY #: , WITNESSES: ADDRESS: 7Y 1441111 G'h 14y P o C -7 -7 PHONE: _72215k1-5'LlYoZ DATE: &/It// y Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 5 ruidauneiii IIUIIIDUI i Page 79 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM 1, 0 G h h Imo' L14</ ?LU_ do hereby apply for retirement under the City of Clearwater General) Employees' Pension Plan. Job Classification: l 0,?1Sv?TG?? --L ?'t S li? PC?? Sex: (9 F Department: Division: Benefits Date: _ 30 18'6 Date of Hire: Date of Birth: 9 S S Resignation Date: 70(4/0 Spouse's Name: S 1 QV O h Sex: M - (0 Spouse's Date of Birth: _ a a 3 S? 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 - if _ Ann iitT 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 # 5 Hnac Page 80 of 138 Option e - 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 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 #: __?__ Description: Life Annuity Employee's Signature: Date: If takina Option 3.4. 5, or 6 fill in beneficiarv information and sign below: Option #: (O Description: / Gb ?(1 ?f Ui.n ?' °` ?`yy' ?©?r/i1V?X t, My desigNted bene$ arv is Name: -?r)QIpn ? ?A l?,"). Date of Birth: y s- 5 3 Sex Mo Social Security Number: _ Phone Number: Address: 7 Y 7 ?`r u e. r d 3377y Employee's Signature: Date: r STATE OF FLORIDA The foregoing in rument was acknowled d before me this COUNTY OF PINELLAS 41111 710 by i C-1 t fL who is personally known to me or who has provided as identi atio and who /t e an ath. Notary Public (Signature)/. ?0? d 1GA-h L /:;?d Name of Notary Printed My Commission expires: NOTARY PUBLIC-STATE OF FLORIDA " Deborah L. Ford Commission #DD763426 Rev. 4/08 Expires: MAY 15, 2012 BONDED THRU ATLANTIC B0144DING CO., INC Form #9900-0009 File Name: Pension Entitlement Option Form Item # 5 Page 81 of 138 11 Estimated Pension Worksheet John Richter III LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 7/16/2010 6/30/1980 30.0444 Signature: ?.. Date: ' !r 1 GROSS CALENDAR PENSION YEAR EARNINGS 2005 $41,200.07 2006 $42,277.24 2007 $44,298.03 2008 $45,787.25 2009 $46,683.97 $220,246.56 (5 Year Total) 5/ $44,049.31 (Yearly Avg) 12/ $3,670.78 (Monthly Avg) x 0.0275 (Benefit Rate) x 30.0444 (Yrs of Service) $3,032.88 (Est Mtly Pension) Item # 5 r{irda n Page 82 of 138 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors 11-Jun-10 sm ESTIMATE clract01 Version: Employee Name: John Richter 1-4-96 Employee Date of Birth: 9 5 1953 Marital Status: m Spouse Date of Birth: 2 23 1954 Beneficiary Date of Birth: 2 23 1954 Benefit Commencement Date : 8 1 2010 Estimated Monthly Normal Reti rement Benefit: $3,032.88 Actuarial Equivalent Adjustment Factors: Option 1 J&S Annuity 1.00000 Option 2 Life Annuity 1.09315 Option 3 10 Year Certain 1.07372 Option 4 50% J&S 1.03301 Option 5 75% J&S 1.00535 Option 6 100% J&S 0.97914 ESTIMATE Estimated Monthly Benefit $3,032.88 $3,315.40 $3,256.45 $3,133.00 $3,049.12 $2,969.62 Item # 5 Page 83 of 138 CITY OF CLEARWATER EMPL O PEES' 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,?'? W' ?'I?u ?'?'? 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 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 o vacation i Z!? -r? Y sick floaters /220' Q - bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. WITNESSES: i ? Revised 1/02 Form 119900-0008 EMPLOYEE'S SIGNATURE: n KZAC114 -9- t,Ai"Aal,,, SOCIAL SECURITY #: ADDRESS: 171k 4o e, PHONE: 7 7 /Y ? 7-,F 77SDATE: o // o File Name: Employee Separation Pay Pref Item # 5 Page 84 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM I, CIr? W I// /.'J do hereby apply for retirement under the City of Clearwater Gener I Employees' Pensions P lan. Job Classific _ ' ?d .?Q ST rW U' i'Y) i°O! 0( )e r Sex: M F % 6 Department: rS vlC'fGk Division: Benefits Date: s` o D Date of i-iire: { d0 O Date of Birth: D 4 1- _)(o 7 Resignation Date: ? d 7 /0 Spouse's Name: ? ve l ... U)f ? 11'P" S Sex: M( F,) Spouse's Date of Birth: _21-3 o 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)] 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%, 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 # 5 Page 85 of 138 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. n 1 Option #: 1 Description: _Joint and Survivor Annuity Employee's Signature: Y, LAM Date: / 0 // 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 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 in trument was ack owledged before me this COUNTY OF PINELLAS & / p 1 U by 1f 01 / 1112 R211 f who is personally known to me or who has provided as identif ti on nd who did/?ot an oath. Notary Public ba (Sigure) ?? o ?7>,- ro rC.? Name of Notary Printed My Commission expires: NOTARY PUBLIC-STATE A Deborah L. Fbrd :Commission #DD763426 Expires: MAY 15, 2012 Rev. 4/08 BONDED THRD ATL%_vgTjC BONDLNG CO., INC Form #9900-0009 File Name: Pension Entitlement Option Form Item # 5 Page 86 of 138 Estimated Pension Worksheet Jerry Williams LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 8/20/2010 8/20/1980 30.0000 Prepared by: Deborah Ford Date: 6/10/10 GROSS CALENDAR PENSION YEAR EARNINGS 2004 $32,158.98 2006 $34,329.17 2007 $35,640.39 2008 $37,959.25 2009 $38,349.03 $178,436.82 (5 Year Total) 5/ $35,687.36 (Yearly Avg) 12/ $2,973.95 (Monthly Avg) x 0.0275 (Benefit Rate) x 30.0000 (Yrs of Service) $2,453.51 (Est Mtly Pension) Item # 5 HlldG[ III rern Page 87 of 138 CITY OF CLEARWA TER 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. -VS 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 /01*`_7' q y 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: SOCIAL SECURITY #: WITNESSES: ADDRESS: cl?o PHONE. -1111 504-(?U251 DATE: Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 5 Page 88 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM I, - Ku SSe/ ( K .Ju /i n+,nc, do hereb a l f ti t d y pp y or re remen un er the City of Clearwater Gen eral Employees' Pension Plan . Job Classification ?V ? 1 i C 11'r tJ+ ce 5 TG hCI k C, r7 Sex: F Department: u +'C r u i,ct- Division: Benefits Date: U Date of Hire: Date of Birth: a y / qS Resignation Date: '7// a Spouse's Name: AM- 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 R 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 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 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 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 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 # 5 Page 89 of 138 Option 6 - 100% joint n survivor nnniuty - (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.) 1 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: Option #: Ij Description: 0 yrQ? (:e1+0,a n c f]?)rlu a My designated ben ficiary is: Name: DK i n \ Q n,'Ac, nate of Birth: 1J- Id- ( 70 Sex M? Social Security Number: _ Address: 010 ( LA Employee's Signature: y STATE OF FLORIDA COUNTY OF PINELLAS Rev. 4/08 Form #9900-0009 Phone Number: -7 D 7 SO 4- 8'(j 7 r, ate: G I! i S I 10 The foreg ing ins rument wawa nowledgec /'5' /0 t C)sse personally known to me or who has provided me this 1 /,?/- ? who is as idenY ati n anI d whdi7n?AZa oath. (.ctrl Notary Public (Sign lure) f ??^' 1) eham L - )1 '1-0? Name of Notary Printed My Commission expires: NOTARY PUBLIC-STATE nF F1ORIDA Deborah L. Ford Commission #DD763426 Expires: MAY 15, 2012 BONDED THRU ATLANiTC BOPIDING Co., INC. File Name: Pension Entitlement Option Form Item # 5 Page 90 of 138 0 1 Estimated Pension Worksheet Russell Dunning LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 8/27/2010 1/31/1998 12.5750 Signature: Date: GROSS CALENDAR PENSION YEAR EARNINGS 2005 $41,739.77 2006 $44,234.92 2007 $46,715.71 2008 $47,600.05 2009 $49,418.07 $229,708.52 (5 Year Total) 5/ $45,941.70 (Yearly Avg) 12/ $3,828.48 (Monthly Avg) x 0.0275 (Benefit Rate) x 12.5750 (Yrs of Service) $1,323.94 (Est Mtly Pension) Item # 5 Page 91 of 138 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors ESTIMATE Employee Name: Russell Dunning Employee Date of Birth: 2 24 1945 Marital Status: S Spouse Date of Birth: Beneficiary Date of Birth: 12 12 1970 Benefit Commencement Date : 9 1 2010 15-Jun-10 sm clract01 Version: 1-4-96 Estimated Monthly Normal Retirement Benefit: $1,323.94 Actuarial Equivalent Adjustment Factors: Option 1 J&S Annuity 1.00000 Option 2 Life Annuity 1.00000 Option 3 10 Year Certain 0.94755 Option 4 50% J&S 0.82771 Option 5 75% J&S 0.76206 Option 6 100% J&S 0.70607 ESTIMATE Estimated Monthly Benefit $1,323.94 $1,323.94 $1,254.50 $1,095.84 $1,008.93 $934.79 Item # 5 Page 92 of 138 CITY OF CLEARINA TER EMPL O YEES' SERA RA 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. 1, _ ???'Jar-?- c? ?' ` ? . --..? r ... 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 05, cs vacation 3 I DL• OS- 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: cZ ? C 3 14-y mvoc4 C,?- 11-44tAJ A- 4cj/' C I C G d LAj :x i' e.- /'-L- 3J 74 PHONE: 7a ?t ??C? (ooL?f ?j DATE: ?o 1 JI0 Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 5 Page 93 of 138 e?) )or 14Cc..v v--4 Ge'If 1, -6arh0e-C, - "// of Clearwater General Employees' Pension Plan. Job Classification Department: Benefits Date: _ Date of Birth: Spouse's Name: Spouse's Date of Birth: CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM do hereby apply for retirement under the City Sex: M? Division: Date of Hire: G q a o Resignation Date: 1 /6 V1+ Sex: M 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 beneficiarys 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 # 5 Page 94 of 138 Option 6 - 10 iloin' & tiu vivor 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 Descrip ion: Joint and S uryiyor Ann City Employee's Signature: ?AAj". Date: 4`\%`\10 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 foregoing in j, was 2knowledged before me this COUNTY OF PINELLAS /,I O by-, q ? 6G %`? SC_?l I'd _ who is personally known to me or who has provided as iden' atio and who did/ id of ke n oath. Notary Public C/!J d Ir 'gnatuL I 1 V / Name of Notary Printed My Commission expires: NOTARY Deborah L. Ford r Commission # DD763426 Exrires. MAY 15, 2012 Rev. 4/08 BONDED THRU ATLANTIC BONDING CO., INC. Form #9900-0009 File Name: Pension Entitlement Option Form Item # 5 Page 95 of 138 Estimated Pension Worksheet Barbara Schill LAST DATE PAID: 8/27/2010 BENEFITS DATE 6/19/2000 CREDITED SERVICE 10.1889 Signature: Date: It 6-110 GROSS CALENDAR PENSION YEAR EARNINGS 2004 $42,540.02 2006 $43,941.78 2007 $45,692.51 2008 $47,494.05 2009 $49,009.20 $228,677.56 (5 Year Total) 5/ $45,735.51 (Yearly Avg) 12/ $3,811.29 (Monthly Avg) x 0.0275 (Benefit Rate) x 10.1889 (Yrs of Service) $1,067.90 (Est Mtly Pension) Item # 5 Page 96 of 138 C`T Y OF 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, RV' s ?a'?rS aV, an employee of the City of Clearwater, hereby apply for 'IJ 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 t 3_5_1in1. vacation 3 91! ! 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. `, 150 ?? SOCIAL SECURITY #: WITNESSES: DDRESS: - "9y 0?z PHONE: -. -ATE: jD I t? I d Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 5 Page 97 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM SWORN POLICE AND FIRE PERSONNEL of Clearwater G Job Classification: _ Department: Benefits Date: Of Date of Birth: - Employees' Pension Plan. R 1?cc_ 0 4,'re011' do hereby apply for retirement under the City 1ct. 0 Sex: Q F Division: Date of Hire: C1 0 Resignation Date: 12 a O Spouse's Name: __ ?j Ar 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 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 - loin anti 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)] Option 3 - 10 Year Cprtain R I ifp Anniflty - (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 R s„rvivnr Ann, t, - (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 change t any time. [Section 2.398 (b) (2) (a) (3)] Item Page 98 of 138 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 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 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: Description: Joint and Surveyor 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 #: 13 Description: /0 I-Ct h i f A6- '? U, Yf My desi ated ben fcia Name: MTV - e?n SC r1 Date of Birth: -) b, :z A Sex(F Social Security Number: Phone Number: _ Address: Employee's Signature: /? - Date: /?- STATE OF FLORIDA The forego115C i strument was cknowled? before me this COUNTY OF PINELLAS 10 by rH `Ja 11 ^ S 0.1 who is Notary Public Votary Printed My Commission expires: NOTARY PUBLIC-STATE OF FLCF"' Deborah L. For.- Rev. 4/08 Commission # DD763426 Form #9900-0053 Expires: MAYFAA ,": Pension Entitlement Option Form MM #F5 BONDED THRU ATLANTIC BONDL"JG Co., INC. personally known to me or who has provided Page 99 of TM 1 Estimated Pension Worksheet ?1 Gary Johnson LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 9/24/2010 9/24/1990 20.0000 Signature: Date: / Q GROSS CALENDAR PENSION YEAR EARNINGS 2005 $54,804.88 2006 $57,649.07 2007 $61,232.17 2008 $65,336.38 2009 $68,959.56 $307,982.06 (5 Year Total) 5/ $61,596.41 (Yearly Avg) 12/ $5,133.03 (Monthly Avg) x 0.0275 (Benefit Rate) x 20.0000 (Yrs of Service) $2,823.17 (Est Mtly Pension) Item # 5 Page 100 of 138 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors Police and Fire Members Only 16-Jun-10 sm clract03 Version: August 9, 2000 Employee Name: Gary Johnson Employee Date of Birth: 7 2 1963 Marital Status: s Spouse Date of Birth: Beneficiary Date of Birth: 7 27 1961 Benefit Commencement Date : 10 1 2010 Estimated Monthly Normal Retirement Benefit: $2,823.17 Estimated ...................... ................. Monthly Actuarial Equivalent Adjustment Factors: Benefit Normal Form 1.00000 $2,823.17 Life Annuity 1.00649 $2,841.50 10 Year Certain 1.00000 $2,823.17 50% J&S 0.97606 $2,755.59 67% J&S 0.96632 $2,728.09 75% J&S 0.96153 $2,714.55 100% J&S 0.94742 $2,674.72 Item # 5 Page 101 of 138 W I Y OF CLEi^rRV?A T ER EMPL O YEES' SEPARA 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. I, ?G?fH? ???'? 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 U, O vacation sick floaters bonus hours Lump Sum 6° 3*7 -7 - vacation G' °t? sick floaters bonus hours I understand that my preference cannot be changed once this form is signed and that my de Sion is irrevocable. ,M1 E•'`,./ EMPLOYEE'S SIGNATURE: s SOCIAL SECURITY #: - TNESSES: ADDRESS: PHONE. DATE: 4' Id, /10 Revised 1/02 Form #!9900-0008 File Name: Employee Separation Pay Pref Item # 5 Page 102 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM SWORN POLICE AND FIRE PERSONNEL 1 kCAV?",_j i?A V N of Clearwater General Employees' Pension Plan. Job Classification: TO I ? --c- O((''r '1"`4?1^Cer Department: Benefits Date: 9 Date of Birth: Spouse's Name: Spouse's Date of Birth: Sex..( F Division: Date of Hire: 9 d -_ q 1,2q Resignation Date: My D 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 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 - .lointand 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 Ann?fity 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 .prtain & Life Ann'jit" - (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 -5n% 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 Anne 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 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 # 5 ICc_ do hereby apply for retirement under the City C HllaGnrneni pumper i Page 103 of 138 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 2/3% 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: Dependent children under tMe age of 18 and residing in my household are: Child's Name Sex Date: do bt 116 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 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 foreeoir?g instrument was acknowledged Wore me this COUNTY OF PINELLAS (e +? b by ?ber?- who is personally known to me or who has provided as idenMIWIr t Notary Pu blic Signature) _ L - ? Name of Notary Printed My Commissio907AirP_s: LIC -STATE OF FWR,aA Y UBDeborah L. Ford Commission #DD763426 Rev. 4/08 Expires: MAY 15, 2012 }}pACCpp c Form #9900-0053 BONDED THRu AnAN is a vda6?t;LPension Entitlement Option FormlPbriCt? 9 Are Page 104 of 138 11 Estimated Pension Worksheet -11 Larry Harbert GROSS CALENDAR PENSION YEAR EARNINGS LAST DATE PAID: 9/24/2010 2005 $13,471.19 estimated BENEFITS DATE 9/24/1990 2006 $62,887.33 CREDITED SERVICE 20.0000 2007 $69,285.40 2008 $68,112.34 2009 $73,136.09 2010 $56,179.60 estimated $343,071.95 (5 Year Total) 5/ $68,614.39 (Yearly Avg) 12/ $5,717.87 (Monthly Avg) x 0.0275 (Benefit Rate) x 20.0000 (Yrs of Service) $3,144.83 (Est Mtly Pension) Prepared by: Deborah Ford Date: 6/2/10 Item # 5 ruidauneiii IIUIIIDUI i Page 105 of 138 C{T Y OF Co LEARWA T ER 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. Fa V C., I, , 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 13 vacation 5U ('N' sick 3a _0 floaters bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. WIT ESSES: ,W"tz A( Revised 1/02 Form #19900-0008 EMPLOYEE'S SIGNATURE: SOCIAL SECURITY #: ADDRESS: PHO. _. . '\TE: ! I I l File Name: Employee Separation Pay Pref Item # 5 Page 106 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM SWORN POLICE AND FIRE PERSONNEL I, 1K 015 ??%i I-a Uc. of Clearwater General Employees' Pension Plan. Job Classification: _ Department: Benefits Date: Date of Birth: "7 Spouse's Name: Spouse's Date of Birth: Sex: M 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 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 Anmfity 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 - in Year Certain & Life Anm Lb - (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 Anni ft - (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 - 7.5% Join 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. The beneficiary can beIf61RWVt any time. [Section 2.398 (b) (2) (a) (3)] do hereby apply for retirement under the City 04.4-1 ,` e? Sex IV F Division: Date of Hire: 3 la-ci 8 Resignation Date: 2 sa /10 ,AJA Page 107 of 138vy 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 2/3% 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 Description: Joint and Survivor Annuity Employee's Signature: Date: 4o U/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 #: Z Description: Life Annuity Employee's Signature: Date: If taking Option 3 4 5 6 or 7 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 COUNTY OF PINELLAS The forego. yg instrument wa no led ed before e this r l 10 L2 by d N who is personally known to me or who has provided as who d Notary Public SRjpAName of Notary Printed OFF My Commission expires: Deborah L. Ford 2b 'o ssi Expires: MAY 15, 2012 nQNm= ` HRH ATLAPix'IC i)pNWO CO., TSiG Rev. 4/08 ?tprp , ire Form #9900-0053 File Name: Pension Entitlement Option Form F3'olicel Page 108 of 138 II Estimated Pension Worksheet II Robert Fava LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 5/31/2010 3/29/1989 21.1722 Signature: 04 Date: h(0 GROSS CALENDAR PENSION YEAR EARNINGS 2005 $66,275.93 2006 $68,185.71 2007 $79,950.66 2008 $81,583.19 2009 $76,254.11 $372,249.60 (5 Year Total) 5/ $74,449.92 (Yearly Avg) 12/ $6,204.16 (Monthly Avg) x 0.0275 (Benefit Rate) x 21.1722 (Yrs of Service) $3,612.29 (Est Mtly Pension) Item # 5 ruidauneiii IIUIIIDUI i Page 109 of 138 C: T Y OF CLEAR6VA 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. ?--?? - e- S G M Q 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 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 -? vacation sick 02e O 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: DATE: Revised 1/02 Form #19900-0008 File Name: Employee Separation Pay Pref Item # 5 --ui-IL hull rucr-? Page 110 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM SWORN POLICE AND FIRE PERSONNEL 1, _j ameS ? i ,IFS of Clearwater General Employees' Pension Plan. Job Classification: Pe- z /^,°U 4 Department: i"r Benefits Date: K Q- Date of Birth: Ili VS Spouse's Name: kD,ij I G_ Spouse's Date of Birth: -21161S-(- 2 / Q S'(- Sex: Sex: M (0 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 -.1nint 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)] Option 3 - 10 Year Certain R Life Annijity - (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 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 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% loin 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. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] Item # 5 4 do hereby apply for retirement under the City Sex: QM F Division: Date of Hire: Y LE? Resignation Date: S- 3/ / U ruidauneiii IIUIIIDUI i Page 111 of 138 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 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.) 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 #: 3 Description: f 0 ° Yt'ir LerE? n My desi ated be eficia is: Name: ?+on c- `C is r CLS Date of Birth: 5 G Sex Mo r r Social Security Number: Phone Number: Address: Emoloyee's Signature: Date: A, h STATE OF FLORIDA The foreooin instfumentwas aowledged befor me this COUNTY OF PINELLAS E % t ?/J O by J4 h? FS GJ who is personally known to me or who has provided as identifie i n a ho did/ ri6ae th 4_ tl-t Notary Public gnature) 1 Name of Notary Printed 0 eJ d fG-/ My Commission expires :itOTAWPUBLTIC-STATEOFFLORTDA Deborah L. Ford Commission # DD763426 Rev. 4/08 10"-w" Expires: MAY 15, 2012 BONDED THRU ATLANTIC BONDING CO. INC. I W Form #9900-0053 File Name: Pension 'Entitlement Option Form l e Description: Joint and Survivor Annuity ruidauneiii IIUIIIuei i Page 112 of 138 11 Estimated Pension Worksheet 11 James Thomas LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 8/31/2010 1/4/1988 22.6583 Signature: r Date: Ce tl ( v GROSS CALENDAR PENSION YEAR EARNINGS 2004 $66,859.27 2005 $82,045.37 2006 $75,912.83 2007 $81,347.02 2008 $74,196.69 $380,361.18 (5 Year Total) 5/ $76,072.24 (Yearly Avg) 12/ $6,339.35 (Monthly Avg) x 0.0275 (Benefit Rate) x 22.6583 (Yrs of Service) $3,950.08 (Est Mtly Pension) Item # 5 Page 113 of 138?c City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors Police and Fire Members Only 16-Jun-10 sm clract03 Version: August 9, 2000 Employee Name: James Thomas Employee Date of Birth: 11 13 1956 Marital Status: m Spouse Date of Birth: 2 10 1956 Beneficiary Date of Birth: 2 10 1956 Benefit Commencement Date : 9 1 2010 Estimated Monthly Normal Retirement Benefit: $3,950.08 Estimated ....................................... Monthly Actuarial Equivalent Adjustment Factors: Benefit Normal Form 1.00000 $3,950.08 Life Annuity 1.07607 $4,250.55 10 Year Certain 1.06203 $4,195.12 50% J&S 1.02899 $4,064.59 67% J&S 1.01420 $4,006.17 75% J&S 1.00696 $3,977.58 100% J&S 0.98586 $3,894.22 Item # 5 Page 114 of 138 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, MA r'' A ?(Ct O[ e l° , an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. EMPL O YEES' SEPA RA T/ON PA Y PREFERENCES CiTY OF CLEARV'VATER 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 '7&'V' sick floaters bonus hours Lump Sum C?Lfo- C) vacation 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: PHONE: _ DATE: (e l U Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 5 Page 115 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM SWORN POLICE AND FIRE PERSONNEL I, - 1' I ay K Si eC gad et-t e of Clearwater General Employees' Pension Plan. Job Classification: _?° ll c.r- Department: Benefits Date: _ Date of Birth: Spouse's Name: Spouse's Date of Birth: do hereby apply for retirement under the City i-7 IX 3 PcL vo1 Sex: M G 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 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 be chaenge any time. [Section 2.398 (b) (2) (a) (3)] Iii ??11 SexQ F Division: Date of Hire: S l 7 P`1 Resignation Date: 3 a / d Page 116 of 138 Option 6 - 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. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] Option 7- 66 2/3% Joint & Survivor Annuit?r -(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 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 #: -?- Description: Life Annuity Employee's Signature: Date: If takina Option 3. 4. 5. 6, or 7 fill in beneficiarv information and sign below: Option #: Description: 1 3C.';l v'a tJU./ Avih r y My designed beneficiary is: Name: 7J+>/ rf- ec uclege Date of Birth: iI - Sex MO Social Security Number: `Phone Number: Address: - - - - - Date: 0 Employee's Signature: =Z?A , - STATE OF FLORIDA The foreg ng estrum ant was a knowled ed before the this COUNTY OF PINELLAS t®? /l y by 6 arkcavde'rf-__ -who is personally known to me or who has provi as idea fi t A as who o ed/diN.? ti? Notary Public t d ? i Name of Notary Printed NOTARY PUBLI TA1 F cR- . My Commissjtirr•.expftrah L. Ford ;Commission 15 219 Expires: AJAY Rev. 4/08 BO'IDED THRti ATLS,YrIC BOXDLiG CO, INC to $ iGe Form #9900-0053 File Name: Pension Entitlement Option Form POgm & F5 Page 117 of 138 11 Estimated Pension Worksheet 11 Mark Beaudette GROSS CALENDAR PENSION YEAR EARNINGS LAST DATE PAID: 7/30/2010 2004 $62,947.23 BENEFITS DATE 5/17/1989 2006 $63,833.50 CREDITED SERVICE 21.2028 2007 $70,767.54 2008 $73,877.43 2009 $79,271.28 $350,696.98 (5 Year Total) 5/ $70,139.40 (Yearly Avg) 12/ $5,844.95 (Monthly Avg) x 0.0275 (Benefit Rate) x 21.2028 (Yrs of Service) $3,408.05 (Est Mtly Pension) Prepared by: Deborah Ford Date: 6/16/10 Item # 5 Page 118 of 138 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors Police and Fire Members Only 16-Jun-10 sm clract03 Version: August 9, 2000 Employee Name: Mark Beaudette Employee Date of Birth: 1 2 1957 Marital Status: m Spouse Date of Birth: 11 29 1956 Beneficiary Date of Birth: 11 29 1956 Benefit Commencement Date : 8 1 2010 Estimated Monthly Normal Retirement Benefit: $3,408.05 Estimated ...................... ................. Monthly Actuarial Equivalent Adjustment Factors: Benefit Normal Form 1.00000 $3,408.05 Life Annuity 1.07962 $3,679.41 10 Year Certain 1.06554 $3,631.43 50% J&S 1.03018 $3,510.90 67% J&S 1.01469 $3,458.11 75% J&S 1.00712 $3,432.31 100% J&S 0.98507 $3,357.16 Item # 5 Page 119 of 138?c Ci i i OF C?EAR'vJATER 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. v bee4 i'erc b c- 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 # 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 o2 / vacation -3(-) (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 #: WITNESSES: ADDRESS: bV4?LA ay- ,vve? PHONE: _ --TE: (,/17/10 Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 5 Page 120 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM SWORN POLICE AND FIRE PERSONNEL of Clearwater General Employees' Pension Plan. Job Classification: -r?6 I J c?C_ -S ?c fQ Department: i c Benefits Date: d?3 k`7 Date of Birth: S 6 S do hereby apply for retirement under the City 1 - Sex: 0 F Division: Date of Hire: Resignation Date: 3 / / rJ Spouse's Name: Sex: M F Spouse's Date of Birth: The ype 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 -1 ife 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)] Option 3 - 10 Year Certain & Life Anni ft - (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% 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 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 belie #Cbat any time. [Section 2.398 (b) (2) (a) (3)] --ui-I II IIUIi I-I i Page 121 of 138 Option 6 - 100% Join & Survivor Ann lily - (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 2/3% Joint & Survivor AnnuitT -(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: 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: Ul? My design %ed beneficiary is- 1 J? e + e?'?®ate of Birth: `y?? 6 Y Sex M f Name: -3 ?n Social Security Number: Phone Number: Address: - - -- - _?_ / /y0 Employee's Signature: -Date: STATE OF FLORIDA Th COUNTY OF PINELLAS _ ent was a4npwledged before me--this by <,ibe,-* CUB P,-c7gc,_ who is Notary Public Jotary Printed My Commission expires: Deborah L. Ford Commission # DD763426 -` Expires: MAY 15, 2012 BONDED THRU ATLANTIC BONDING CO., INC. Rev. 4/08 Item # 5 Form #9900-0053 File Name: Pension Entitlement Option Form Police & Fire personally known to me or who has provided ruidauneiii IIUIIIuei i Page 122 of 138 11 Estimated Pension Worksheet Robert Wierzba LAST DATE PAID: 8/27/2010 BENEFITS DATE 3/23/1987 CREDITED SERVICE 23.4278 Signature: Date: { 5 I v GROSS CALENDAR PENSION YEAR EARNINGS 2004 $94,572.16 2006 $88,049.57 2007 $97,970.37 2008 $103,889.83 2009 $100,309.00 $484,790.93 (5 Year Total) 5/ $96,958.19 (Yearly Avg) 12/ $8,079.85 (Monthly Avg) x 0.0275 (Benefit Rate) x 23.4278 (Yrs of Service) $5,205.56 (Est Mtly Pension) Item # 5 Page 123 of 138?c City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors Police and Fire Members Only 15-Jun-10 sm clract03 Version: August 9, 2000 Employee Name: Robert Wierzba Employee Date of Birth: 5 5 1965 Marital Status: S Spouse Date of Birth: Beneficiary Date of Birth: 4 26 1940 Benefit Commencement Date : 9 1 2010 Estimated Monthly Normal Retirement Benefit: $5,205.56 Estimated ...................... ................. Monthly Actuarial Equivalent Adjustment Factors: Benefit J&S Annuity 1.00000 $5,205.56 Life Annuity 1.00516 $5,232.40 10 Year Certain 1.00000 $5,205.56 50% J&S 0.99824 $5,196.40 - -" 67% J&S 0.99596 $5,184.51 75% J&S 0.99482 $5,178.58 _ 100% J&S 0.99142 $5,160.89 Item # 5 Page 124 of 138 G/TY OF CLEARWA 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. 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 floaters bonus hours Jam' d vacation p9WU'96 sick -d 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: D V W? Revised 1/02 Form #9900-0008 ADDRESS: PHONE: DATE: File Name: Employee Separation Pay Pref Item # 5 Page 125 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM SWORN POLICE AND FIRE PERSONNEL 1, Nd / m CL -\ (? ,-,q of Clearwater General Employees ension Plan. do hereby apply for retirement under the City Job Classification: T;." C- I ' `-rd -- = )t i 2iJ 't e in a ?I f Sex: M F Department: f Division: Benefits Date: Date of Hire: i SZ Date of Birth: 3 t Resignation Date: F: 3/ /0 Spouse's Name: Spouse's Date of Birth: Sex: M F The type of pension for which I am applying is (check only one): ?2k_ 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 Annui 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 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 # 5 Page 126 of 138 Oration 6 - 100%, Join & S ,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. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] Option 7 66 213% Joint & Survivor Annirit* - (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: Dependent children under the age of 18 and residing in my household are: Child's Name Sex Description: Joint and Survivor Annuity Date: Date of Birth If taking Option 2 sign below: Option #: 2 Description: Life Annuity Employee's Signature: Date: Option #: 17 Description: /b.- P My desigt?ted beneficiary is: /?7 Name: ni 44- Qn Date of Birth: ?9 U Sex MO F Social Security Number Address: Emoloyee's Sicnature:. I I- f 4-C' hhC/ / -T Phone Numb Date: _ ( 7 STATE OF FLORIDA The for oing instrument was acknoVIedged before me this COUNTY OF PINELLAS by nr?? Gr1 who is personally known to me or who has provided as ide ti cati nd wh id/ i ` of e o Notary Public (Signs/lure) O fct-11 L - A /'--( Name of Notary Printed My Commission expires: :rOTA-1,YPOBLIC-5TATE0F11'L0FJ1)A lieu 1-ah =Commission #DD763426 Expires: Iv1AY 15, 2012 ??}t ??{{ FF Rev. 4/08 npttCiEtj TUU An AMC 00N CA,, Nr" e Form #9900-0053 File Name: Pension Entitlement Option Form f'gi &?Fh' Page 127 of 138 IL_ Estimated Pension Worksheet 1 Norman Jernigan GROSS CALENDAR PENSION YEAR EARNINGS LAST DATE PAID: 8/31/2010 2005 $81,167.99 BENEFITS DATE 1/6/1986 2006 $78,762.75 CREDITED SERVICE 24.6528 2007 $78,821.29 2008 $82,162.42 2009 $83,765.44 $404,679.89 (5 Year Total) 5/ $80,935.98 (Yearly Avg) 12/ $6,744.67 (Monthly Avg) x 0.0275 (Benefit Rate) x 24.6528 (Yrs of Service) $4,572.56 (Est Mtly Pension) Prepared by: Deborah Ford Date: 6/17/10 Item # 5 Page 128 of 138 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors Police and Fire Members Only 17-Jun-10 sm clract03 Version: August 9, 2000 Employee Name: Norman Jernigan Employee Date of Birth: 2 13 1962 Marital Status: s Spouse Date of Birth: Beneficiary Date of Birth: 8 9 1990 Benefit Commencement Date : 9 1 2010 Estimated Monthly Normal Retirement Benefit: $4,572.56 Estimated ...................... ................. Monthly Actuarial Equivalent Adjustment Factors: Benefit Normal Form 1.00000 $4,572.56 Life Annuity 1.00803 $4,609.30 10 Year Certain 1.00000 $4,572.56 50% J&S 0.93847 $4,291.23 67% J&S 0.91737 $4,194.74 75% J&S 0.90717 $4,148.11 100% J&S 0.87789 $4,014.22 Item # 5 Page 129 of 138 CITY OF "EAn V, 1A T ER CL EPIA 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? uJ ? 2? c 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 # 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 C7 -i vacation -1 Y a° d sick '94' 0 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: PHONE: MATE: l 's,' Revised 1/02 Form #9900-0008 File Name: Employee Separation Pay Pref Item # 5 Page 130 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM SWORN POLICE AND FIRE PERSONNEL of Clearwater General Employees' Pension Plan. Job Classifications Department: Benefits Date: I o Date of Birth: % ce. O Spouse's Name: Spouse's Date of Birth: do hereby apply for retirement under the City ,n t Sex: 9 F Division: Date of Hire: I is ?d- Resignation Date: 3' 3t /a --,Nor 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 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 -.loint 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 P. Survivor Annni 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 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 chaengeO 9 any time. [Section 2.398 (b) (2) (a) (3)] Page 131 of 138?c 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 21 3% Jnint & S„rvivnr Anni i -(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 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 takina Option 3.4. 5. 6, or 7 fill in beneficiary information and siqn below: Option #: Description: I &V 0XV' Sdin'f- , Irv, ?.?? A,1,7u) &- , My designated beneficiaryName:She.'I? t:Ua4r+? tf(44ate of Birth: Sex MO Social Security Number:. Phone Number: - Address: , i ' Employee's Signature: - Date: I bo STATE OF FLORIDA The fore ing instrument was acknowledged before me thi COUNTY OF PINELLAS 4?kY_ 10 by Let W?ZnCe j? a?I u',c who is personally known to me or who has provided as id oath. //t - = "/ Notary Public (Signature) ?'bUtQ?h L FT)v Name of Notary Printed NOTARY PL L My Commission expires: ?. s Expi _ r T;::u "`l Rev. 4/08 Item # 5 Form #9900-0053 File Name: Pension Entitlement Option Form Police & Fire Page 132 of 138 Estimated Pension Worksheet Lawrence Borland LAST DATE PAID: 8/31/2010 BENEFITS DATE 10/18/1982 CREDITED SERVICE 27.8694 GROSS CALENDAR PENSION YEAR EARNINGS 2005 $75,604.04 2006 $80,137.25 2007 $87,141.35 2008 $85,417.92 2009 $85,450.40 $413,750.96 (5 Year Total) 5/ $82,750.19 (Yearly Avg) 12/ $6,895.85 (Monthly Avg) x 0.0275 (Benefit Rate) x 27.8694 (Yrs of Service) $5,285.05 (Est Mtly Pension) Prepared by: Deborah Ford Date: 6/18/10 Item # 5 Page 133 of 138 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors Police and Fire Members Only 18-Jun-10 sm clract03 Version: August 9, 2000 Employee Name: Lawrence Borland Employee Date of Birth: 2 12 1950 Marital Status: m Spouse Date of Birth: 11 26 1968 Beneficiary Date of Birth: 11 26 1968 Benefit Commencement Date : 9 1 2010 Estimated Monthly Normal Retirement Benefit: $5,285.05 Estimated ...................... ................. Monthly Actuarial Equivalent Adjustment Factors: Benefit Normal Form 1.00000 $5,285.05 Life Annuity 1.21925 $6,443.81 10 Year Certain 1.18486 $6,262.03 50% J&S 1.07578 $5,685.54 67% J&S 1.03517 $5,470.94 75% J&S 1.01600 $5,369.60 100% J&S 0.96251 $5,086.93 Item # 5 MLLdauneiu iiwiiuer-F_ Page 134 of 138 CiT Y OF C LEARWATER 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. m e 1" `K , 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 65'J- 71- vacation 35-• 4 3 sick floaters bonus hours I understand that my preference cannot be changed once this form is si ned and that my decision is irrevocable. EMPLOYEE'S SIGNATURE: SOCIAL SECURITY #: WI NESSES: ADDRESS: &A4??k Y AW Revised 1/02 Form #9900-0008 PHONE: yATE: d File Name: Employee Separation Pay Pref Item # 5 Page 135 of 138 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM SWORN POLICE AND FIRE PERSONNEL of Clearwater General Employees' Pensiioon? Plan. Job Classification: /Q k Department: o C_ Benefits Date: 0-3/8-1 Date of Birth: 11.20 It. b Spouse's Name: C-?rl 1 C, Spouse's Date of Birth: `1 3p lo). do hereby apply for retirement under the City Sex: ® F Division: Date of Hire: 3 ?'? Resignation Date: a /U uC Sex: M o The pe 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 Siirvivor 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 t8. [Section 2.397 (a) (3) and Section 2.398 (b) (1)] Option 2 - Life Annui 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 R Life AnniW:y - (must designate a beneficiary) The Participant receives his/her pension as long as he/she lives. If the Participant dies b "for _ 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 P. Survivor Ann !W - (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 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 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 bejfb rqpdjat any time. [Section 2.398 (b) (2) (a) (3)] Page 136 of 138 Option 6 - 100%, hint & Survivor Anntji 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. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] Option 7 - 66 2/3% 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 66 213% 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: 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: I "r -)0rvJ'VC My desi ated be efici??Y is: Name: U?yct 1, t Lick- Date of Birth: 7 30 L -A, Sex Me Social Security Number: - Address: Signature: Description: Joint and Survivor Annuity Phone Number: Date: 64y/, U STATE OF FLORIDA Qareing instrument was acck owled ed b fore e this a 140 COUNTY OF PINELLAS by ?JQme g vc who is personally known to me or who has provided as ide if cati h ai d who d/dta KV4 a Notary Public (Signature) ? 1 140 el0-A 4- Gild Name of Notary Printed My Commission expirWTARY PUBLIC-sTATF n81361 Deborah L. Ford Commission #DD763426 Rev. 4/08 ' •' Expires: MAY 15, 2012 ED THRU AzLA?r I }p 13 OND }?o?icme Form #9900-0053 File ?laror?e?iifEntitlement Option Form &' Fire Page 137 of 138 11 - Estimated Pension Worksheet 11 James Houck LAST DATE PAID: BENEFITS DATE CREDITED SERVICE Prepared by: Date: GROSS CALENDAR PENSION YEAR EARNINGS 8/31/2010 2005 $64,501.90 4/3/1989 2006 $61,214.92 21.4111 2007 $64,157.35 2008 $71,097.10 2009 $73,184.44 $334,155.71 (5 Year Total) 5/ $66,831.14 (Yearly Avg) 12/ $5,569.26 (Monthly Avg) x 0.0275 (Benefit Rate) x 21.4111 (Yrs of Service) $3,279.21 (Est Mtly Pension) Deborah Ford 6/14/10 Item # 5 Page 138 of 138 City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors Police and Fire Members Only 14-Jun-10 sm clract03 Version: August 9, 2000 Employee Name: James Houck Employee Date of Birth: 1 20 1960 Marital Status: m Spouse Date of Birth: 7 30 1962 Beneficiary Date of Birth: 7 30 1962 Benefit Commencement Date : 9 1 2010 Estimated Monthly Normal Retirement Benefit: $3,279.21 Estimated ................. ................. Monthly Actuarial Equivalent Adjustment Factors: Benefit Normal Form 1.00000 $3,279.21 Life Annuity 1.07717 $3,532.28 10 Year Certain 1.06669 $3,497.91 50% J&S 1.02881 $3,373.67 67% J&S 1.01363 $3,323.92 75% J&S 1.00621 $3,299.59 100% J&S 0.98459 $3,228.69 Item # 5