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08/29/2011PENSION TRUSTEES AGENDA Location: Council Chambers - City Hall Date: 8/29/2011- 9:00 AM 1. Call to Order 2. Approval of Minutes 2.1 Approve the minutes of the August 15, 2011 Pension Trustees meeting as submitted in written summation by the City Clerk. Attachments 3. Pension Trustee Items 3.1 Approve new hires for acceptance into the Pension Plan as listed. El Attachments 3.2 Approve the requests of employee Richard Breest, Police Department; Michael Waters, Police Department; Sharon Imray, Police Department; John Horning, Police Department; Randy Holm, Gas Department; Nick Gossman, Police Department; Tracey Bruch, Engineering Department; and John Schuster, Public Utilities Department, for a regular pension as provided by Sections 2.397 and 2.398 of the Employees' Pension Plan. El Attachments 3.3 Approve the request of employee Colleen Lau, Police Department, to vest her pension as provided by Section 2.397 of the Employees' Pension Plan. El Attachments 4. Other Business 5. Adjourn Pension Trustees Agenda Council Chambers - City Hall Meeting Date:8 /29/2011 SUBJECT / RECOMMENDATION: Approve the minutes of the August 15, 2011 Pension Trustees meeting as submitted in written summation by the City Clerk. SUMMARY: Review Approval: Cover Memo Attachment number 1 Page 1 of 4 TRUSTEES OF THE EMPLOYEES' PENSION FUND MEETING MINUTES CITY OF CLEARWATER August 15, 2011 Present: Chair/Trustee Frank Hibbard, Trustee George N. Cretekos, Trustee John Doran, Trustee Paul Gibson, and Trustee Bill Jonson. Also Present: Jill S. Silverboard - Assistant City Manager, Rod Irwin - Assistant City Manager, Pamela K. Akin - City Attorney, Rosemarie Call - City Clerk, and Nicole Sprague — Official Records and Legislative Services Coordinator. Unapproved To provide continuity for research, items are agenda order although not necessarily discussed in that order. 1. Call to Order— Chair Frank Hibbard The meeting was called to order at 3:13 p.m. at City Hall. 2. Approval of Minutes 2.1 Approve the minutes of the July 18, 2011 Pension Trustees Meeting as submitted in written summation by the City Clerk. Trustee John Doran moved to approve the minutes of the July 18, 2011 Pension Trustees Meeting as submitted in written summation by the City Clerk. The motion was duly seconded and carried unanimously. 3. Pension Trustee Items 3.1 Approve new hires for acceptance in the Pension Plan as listed. Name, Job. Class, & Dept. /Div. Hire Date Pension Elig. Date Sherman Young, Police Officer /Police 5/23/11 5/23/11 Nathaniel Bowne, Custodial Worker /Parks & Recreation 1/15/04 4/9/11 Matthew Jackson, Planner II /Planning & Development 5/31/11 5/31/11 Pension Trustees 8/15/2011 1 Attachment number 1 Page 2 of 4 Nathaniel Browne originally was hired as part -time on November 15, 2004; transferred to full -time and pension eligible as of April 9, 2011 Trustee George Cretekos moved to approve new hires for acceptance in the Pension Plan as listed. The motion was duly seconded and carried unanimously. 3.2 Approve the requests of employee Dirk Curls, Police Department; Stephen Doherty, Engineering Department; and Marlinda Neal, Customer Service Department, for a regular pension as provided by Sections 2.397 and 2.398 of the Employees' Pension Plan. Dirk Curls, Police Sergeant, Police Department, was employed by the City on January 7, 1985, and his pension service credit is effective on that date. His pension will be effective October 1, 2011. Based on an average salary of approximately $87,439 per year over the past five years, the formula for computing regular pensions, and Mr. Curls' selection of the 75% Joint & Survivor Annuity, this pension will approximate $64,641 annually. Stephen Doherty, Engineering Specialist!, Engineering Department, was employed by the City on August 19, 1985, and his pension service credit is effective on that date. His pension will be effective September 1, 2011. Based on an average salary of approximately $60,730 per year over the past five years, the formula for computing regular pensions, and Mr. Doherty's selection of the Life Annuity, this pension will approximate $47,636 annually. Marlinda Neal, Senior Customer Service Representative, Customer Service Department, was employed by the City on August 17, 1981, and her pension service credit is effective on that date. Her pension will be effective September 1, 2011. Based on an average salary of approximately $45,253 per year over the past five years, the formula for computing regular pensions, and Ms. Neal's selection of the 10 -year Certain & Life Annuity, this pension will approximate $37,036 annually. Section 2.397 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 2.397 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 Sergeant as meeting the hazardous duty criteria. Mr. Doherty qualifies under the age 55 and twenty years of service criteria. Ms. Neal qualifies under the 30 years of service criteria. Mr. Curls qualifies under the hazardous duty criteria. Pension Trustees 8/15/2011 2 Attachment number 1 Page 3 of 4 Trustee Paul Gibson moved to approve the requests of employee Dirk Curls, Police Department; Stephen Doherty, Engineering Department; and Marlinda Neal, Customer Service Department, for a regular pension as provided by Sections 2.397 and 2.398 of the Employees' Pension Plan. The motion was duly seconded and carried unanimously. 3.3 Approve the request of employee Brian Murphree, Parks and Recreation Department, and Steven DeSimone, Gas Department, to vest their pensions as provided by Section 2.397 of the Employees' Pension Plan. Brian Murphree, Landscape Manager, Parks and Recreation Department, was employed by the City on November 20, 2000, and began participating in the Pension Plan on that date. Mr. Murphree terminated from City employment on June 17, 2011. Steven DeSimone, Gas Technician III, Gas Department, was employed by the City on July 16, 1990, and began participating in the Pension Plan on that date. Mr. DeSimone terminated from City employment on June 23, 2011. The Employees' Pension Plan provides that should an employee cease to be an employee of the City of Clearwater or change status from full -time to part -time after completing ten or more years of creditable service (pension participation), such employee shall acquire a vested interest in the retirement benefits. Vested pension payments commence on the first of the month following the month in which the employee normally would have been eligible for retirement. Section 2.397) provides for normal retirement eligibility when a participant has reached age 55 and completed twenty years of credited service, has completed 30 years of credited service, or has reached age 65 and completed ten years of credited service. Mr. Murphree would have completed at least 20 years of service and reached age 55 on July 24, 2028. His pension will be effective August 1, 2028. Mr. DeSimone would have completed at least 20 years of service and reached age 55 on September 12, 2016. His pension will be effective October 1, 2016. Trustee Bill Jonson moved to approve the request of employee Brian Murphree, Parks and Recreation Department, and Steven DeSimone, Gas Department, to vest their pensions as provided by Section 2.397 of the Employees' Pension Plan. The motion was duly seconded and carried unanimously. 4. Other Business — None. 5. Adiourn The meeting was adjourned at 3:14 p.m. Pension Trustees 8/15/2011 3 Attest City Clerk Attachment number 1 Page 4 of 4 Chair Employees' Pension Plan Trustees Pension Trustees 8/15/2011 4 Pension Trustees Agenda Council Chambers - City Hall SUBJECT / RECOMMENDATION: Approve new hires for acceptance into the Pension Plan as listed. SUMMARY: Name, Job. Class, & Dept./Div. Hire Date Charles King, SWEquip. Oper. /Solid Waste /General Ser. Frank Ciafone, WWTP Operator Trainee /Pub. Util. Steve Heppler, WWTP Operator C/Public Utilities Sean Hailey, Police Communications Operator/Police Heather Husted, Librarian II/Library Freda Daniels, Customer Service Rep. /Customer Service Charles Lane, Real Estate Coodirnator/Engineering Valerie Craig, Recreation Leader/Parks & Recreation Jesse Jones, Utilities Chemist/Public Utilities 3/19/10 7/2/11 7/18/11 7/16/11 10/26/09 7/7/10 8/1/11 8/1/11 8/1/11 Pension Elig. Date Meeting Date:8 /29/2011 *Resigned on 2/11/11; rescinded resignation effective 7/5/11; pension eligible as of that date since he received a refund of his pension contributions * *Originally hired as part-time on 10/26/09; promoted to full -time position and pension eligible as of 7/16/11 ** *Originally hired as part-time 7/7/10; status changed to full -time and pension eligible as of 7/4/11. Review Approval: Cover Memo Pension Trustees Agenda Council Chambers - City Hall Meeting Date:8 /29/2011 SUBJECT / RECOMMENDATION: Approve the requests of employee Richard Breest, Police Department; Michael Waters, Police Department; Sharon Imray, Police Department; John Horning, Police Department; Randy Holm, Gas Department; Nick Gossman, Police Department; Tracey Bruch, Engineering Department; and John Schuster, Public Utilities Department, for a regular pension as provided by Sections 2.397 and 2.398 of the Employees' Pension Plan. SUMMARY: Richard Breest, Police Sergeant, Police Department, was employed by the City on December 12, 1986, and his pension service credit is effective on that date. His pension will be effective September 1, 2011. Based on an average salary of approximately $99,967 per year over the past five years, the formula for computing regular pensions, and Mr. Breest's selection of the Life Annuity, this pension will approximate $72,651 annually. Michael Waters, Police Lieutenant, Police Department, was employed by the City on August 18, 1986, and his pension service credit is effective on that date. His pension will be effective September 1, 2011. Based on an average salary of approximately $110,229 per year over the past five years, the formula for computing regular pensions, and Mr. Waters' selection of the 100% Joint & Survivor Annuity, this pension will approximate $74,682 annually. Sharon Imray, Police Officer, Police Department, was employed by the City on May 14, 1990, and her pension service credit is effective on that date. Her pension will be effective September 1, 2011. Based on an average salary of approximately $67,780 per year over the past five years, the formula for computing regular pensions, and Ms. Imray's selection of the 100% Joint & Survivor Annuity, this pension will approximate $38,838 annually. John Horning, Police Department, was employed by the City on May 20, 1991, and his pension service credit is effective on that date. His pension will be effective September 1, 2011. Based on an average salary of approximately $77,720 per year over the past five years, the formula for computing regular pensions, and Mr. Horning's selection of the 100% Joint & Survivor Annuity, this pension will approximate $42,905 annually. Randy Holm, Gas Supervisor, Gas Department, was employed by the City on June 11, 1984, and his pension service credit is effective on that date. His pension will be effective November 1, 2011. Based on an average salary of approximately $55,518 per year over the past five years, the formula for computing regular pensions, and Mr. Holm's selection of the 100% Joint & Survivor Annuity, this pension will approximate $40,873 annually. Nick Gossman, Police Communications Supervisor, Police Department, was employed by the City on June 20, 1989, and his pension service credit is effective on January 18, 1990. His pension will be effective October 1, 2011. Based on an average salary of approximately $64,636 per year over the past five years, the formula for computing regular pensions, and Mr. Gossman's selection of the 100% Joint & Survivor Annuity, this pension will approximate $37,588 annually. Tracey Bruch, Parking Manager, Engineering Department, was employed by the City on September 15, 1980, and her pension service credit is effective on that date. Her pension will be effective October 1, 2011. ernsoBased on an average salary of approximately $77,868 per year over the past five years, the formula for computing regular P eins, and Ms. Bruch's selection of the Life Annuity, this pension will approximate $70,214 annually. John Schuster, Wastewater Treatment Plant Operator B, Public Utilities Department, was employed by the City on September 8, 1981, and his pension service credit is effective on that date. His pension will be effective October 1, 2011. Based on an average salary of approximately $60,713 per year over the past five years, the formula for computing regular pensions, and Mr. Schuster's selection of the Joint & Survivor Annuity, this pension will approximate $50,088 annually. Section 2.397 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 2.397 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 Sergeant, Police Lieutenant, and Police Officer as meeting the hazardous duty criteria. Mr. Holm and Mr. Gossman qualify under the age 55 and twenty years of service criteria. Ms. Bruch and Mr. Schuster qualify under the 30 years of service criteria. Mr. Breest, Mr. Waters, Mr. Horning, and Ms. Imray qualify under the hazardous duty criteria. Review Approval: Cover Memo PREFERENCE #1 PREFERENCE #2 CITY OF CLEARWATER EMPLOYEES' SEPARATION PAY PREFERENCES 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. 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 g .Etrs n'v Uer 1 f 20 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 and wish my benefits to be calculated under this preference. Please use my pay preference # l leave in the following manner: Run Out vacation sick floaters bonus hours Lump Sum .q 'l. °23 vacation 64' 45 sick floaters bonus hours 1 understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. EM PLOYEE'S SIGNATURE K 1673 �'�e" SOCIAL SECURITY #• TNESSES: 4p ADDRESS: - - PHONE: DATE• 7// (P 11 Revised 1/02 Form #9900 -0008 File Name: Employee Separation Pay Pref per 1 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM SWORN POLICE AND FIRE PERSONNEL of Clearwater General Employees' Pension Plan. olr "ce_ Job Classification: Department: Benefits Date: Date of Birth: Spouse's Name: Spouse's Date of Birth: do hereby apply for retirement under the City ✓�j CO VIA-- UU Division: Date of Hire: Resignation`` Date: 3c .r 6ar� 'Tr-1--- o 14 I Ste Seel F tal l3tlit Sex: M The $e 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 Attachment num Page 2 of 20 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 - Jointand 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 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 fives. If the Participant dies first, the beneficiary receives 50% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his /her pension and upon his/her death, benefits cease. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his /her pension as long as he /she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his /her pension and upon his /her death, benefits cease. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] 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 a_ s Option 1) and the various altemative 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. ttacnment number Page 3 of 20 If taking Option 1 sign below: Option #: 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_ Employee's Signature: Description: Life Annuity 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 Rev. 4/08 Form #9900 -0053 The foregoing strument was owl dged bP� re this % /I Y// by ti G YdK._ e of who is personally known to me or who has provided as identif a on .j d o did/ (signs re) Notary Public Name of Notary Printed My Comrors PA C-SSTATE OF FLORIDA - Deborah L. Ford Commission #DD763426 ;- Expires: MAY15,2Q 2, BONDED THRC ATI. IC BONDllgc c .,'i,'�T(?�ame. Pension Entitlement Option Form Police & Fire Estimated Pension Worksheet Richard Breest LAST DATE PAID: BENEFITS DATE CREDITED SERVICE Prepared by: Date: 8/31/2011 12/12/1986 24.7194 Deborah Ford 7/14/2011 GROSS CALENDAR PENSION YEAR EARNINGS 2006 - $93,464:47 2007 $103,403.08 2008 $101,180.84 2009 $99,401.31 2010 $102,384.19 $499,833.89 5/ $99,966.78 12/ $8,330.57 Attachment number 1 Page 4 of 20 (5 Year Total) (Yearly Avg) (Monthly Avg) x 0.0275 (Benefit Rate) x 24.7194 (Yrs of Service) $5,662.99 (Est Mtly Pension) City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors Police and Fire Members Only Employee Name: Employee Date of Birth: Marital Status: Spouse Date of Birth: Beneficiary Date of Birth: Benefit Commencement Date : Richard Breest 8 25 1958 m 11 4 1956 11 4 1956 9 1 2011 Estimated Monthly Normal Retirement Benefit: $5,662.99 15-Jul-11 sm clract03 Version: August 9, 2000 Actuarial Equivalent Adjustment Factors: J &S Annuity Life Annuity 10 Year Certain 50% J &S 67% J &S 75% J &S 100% J &S 1.00000 1.06909 1.05645 1.02642 1.01295 1.00634 0.98703 Attachment number 1 Page 5 of 20 Estimated Monthly Benefit $5,662.99 $6,054.25 $5,982.69 $5,812.62 $5,736.30 $5,698.89 $5,589.53 PREFERENCE #1 PREFERENCE #2 CITY OF CLEARWATER EMPLOYEES' SEPARATION PAY PREFERENCES 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. 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. Pensioptllig4 ,r 11 begin the following month. Page 6 of 20 1, '01 it-11 c eA 0,1OL4-c es , 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 02GD)' (460 vacation '78'.b' ° sick 3c)?, °floaters bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. TNESSES: Revised 1/02 Form #9900 -0008 EMPLOYEE'S SIGNATURE- X. at ' SOCIAL SECURITY #• ADDRESS: PHONE: — DATE- 7 /IIII File Name: Employee Separation Pay Pref ar 1 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM SWORN POLICE AND FIRE PERSONNEL 1, rYl f ce.( U..) ev of Clearwater General Employees' Pension Plan. do hereby apply for retirement under the City Job Classification: �o 11 C,i` L ( to i-r n G ✓14 Department: poi i'ce-- Division' Benefits Date: ' 1 )1s1 to Date of Hire' Date of Birth: CI 14.ci 1 to I Resignation Date' Spouse's Date of Birth: 10 1 1�JG3 Spouse's Name: Sex: CM s�ll�i�c� Sex: The tv�e of pension for. which I am applying is (check only one): V Regular Pension based on years of service Job - connected Disability Pension Non -job- connected Disability Pension Early Retirement Attachment numb Page 7 of 20 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)] 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. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his /her pension as long as he /she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his /her life. If the beneficiary dies first, the Participant continues to receive 100% of his /her pension and upon his /her death, benefits cease. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] Option 6 - 100% Joint & Survivor Annriity - (must designate a beneficiary) The Participant receives his/her pension as long as he /she lives. If the Participant dies first, the beneficiary receives 100% of the pension for the rest of his/her life. If the beneficiary dies first, the Participant continues to receive 100% of his /her pension and upon his/her death, benefits cease. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] Option 7 - 66 213% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his/her pension as long as he /she lives. If the Participant dies fi rst, 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 rttacnment number Page 8of20 If taking Option 1 sign below: Option it 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, 6, or 7 fill in beneficiary information and sign below: 0' Option #: b Description: / i/ �y `� 0 i 'i+ SG r V ' V o ✓ /'y 'Irk/ /s.9 My design ted benefi ry ia i : Name: � 5 c1/4. ova CY:S_ Date of Birth: 1 O (d- 1 �s Sex MO Social Security Number: Address: Employee's Signature: Phnna Nh "mher: Date: STATE OF FLORIDA COUNTY OF PINELLAS Rev. 4/08 Form #9900 -0053 The foregoing ir}strument was acknowledge befo e m this 7/V4 / / i by 01 , t-h 4 e- I tt�rS who is personally known to me or who has provided aside4catir/ .nd who ././did r,Ja - - ',oath. lti ■•IS /A '►L4si Notary Public (Signature) be. cr J) L My Commission expires: ✓ Name of Notary Printed NOTARY PUBLIC -STATE OF FLORIDA e Deborah i. Ford ;.d ,• Commission #DD763426 `•..,,,,,,,, Expires: MAY 15, 2012 BONDED THRU ATLANTIC BONDING CO., INC. File Name: Pension Entitlement Opft~on Form Police & Fire Estimated Pension Worksheet Michael Waters LAST DATE PAID: BENEFITS DATE CREDITED SERVICE Prepared by: Date: 8/26/2011 8/18/1986 25.0222 Deborah Ford 6/21/2011 GROSS CALENDAR PENSION YEAR EARNINGS 2006 $45,996.11 2007 $105,929.90 2008 $107,121.13 2009 $111,114.02 2010 $110,689.93 2011 $70,292.17 $551,143.26 5/ $110,228.65 12/ $9,185.72 estimated (2006 pension gross divided by 26 x 12 pay periods) Attachment number 1 Page 9of20 estimated (2011 pension gross ytd of $48,776.41 plus 6 add'I pays x b/w gross of $3585.96) (5 Year Total) (Yearly Avg) (Monthly Avg) x 0.0275 (Benefit Rate) x 25.0222 (Yrs of Service) $6,320.80 (Est Mtly Pension) City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors Police and Fire Members Only Employee Name: Employee Date of Birth: Marital Status: Spouse- Date of Birth: Beneficiary Date of Birth: Benefit Commencement Date : Michael Waters 9 29 1961 m 10 12 1965 10 12 1965 9 1 2011 Estimated Monthly Normal Retirement Benefit: $6,320.80 14- Jul -11'_ sm clract03 Version: August 9, 2000 Actuarial Equivalent Adjustment Factors: J &S Annuity Life Annuity 10 Year Certain 50% J &S 67% J &S 75% J &S 100% J &S 1.00000 1.07590 1.06642 1.02823 1.01327 1.00595 0.98461 Attachment number 1 Page 10 of 20 Estimated Monthly Benefit $6,320.80 $6,800.57- $6,740.65 $6,499.26 $6,404.67 $6,358.39 $6,223.51 PREFERENCE #1 CITY OF CLEARWATER EMPLOYEES' SEPARATION PAY PREFERENCES 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, oating o l•ay pay, sic eave incen ive, .onus says l 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 fin lttRAMMAber Termination date will be the final day of extended time. Pension bfitc2D ✓ ill begin the following month. 7:3"; h'n C f , 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 30.17 vacation 7 3 S 10 sick 302-6 floaters bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. WITNESSES: EMPLOYEE'S SIGNATURE- SOCIAL SECURITY # DDRESS: Revised 1/02 Form X79900 -0008 PHONE: �..TE File Name: Employee Separation Pay Pref umber 1 7 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM SWORN POLICE AND FIRE PERSONNEL 1, rc i.i et Ie''e / `y1 of Clearwater General Employees' Pensioo/Plan. Job Classification: Department: Benefits Date: Date of Birth: Spouse's Name: Spouse's Date of i ■1 t'c_>e © rc C ►� Division: 5 14 9 / Date of Hire: 514 -0 h/ 3 1S Resignation Date: /.3/// do hereby apply for retirement under the City Sex: O F 413e cc-a-- Birth: it ll 71(03 .4,) Sex: M� The type of pension for which I am applying is (check only one): yL Regular Pension based on years of service Job - connected Disability Pension Non -job- connected Disability Pension Early Retirement Attachment r Page 12 of 2 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)] 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. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his /her pension as long as he /she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his /her life. If the beneficiary dies first, the Participant continues to receive 100% of his /her pension and upon his /her death, benefits cease. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] - i i ° , •'a .. i i . � n v ttity - (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 altemative 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 irrevocabkachmentnurnber 1 ge 13 of 20 If taking Option 1 sign below: Option #: _ 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, 6, or 7 fill in beneficiary information and sign below: Description: 5 cry, '✓� "J' �Yt h v1 Option #: 1D My desi ateid beneficia is: Name: je f9fC3U- e✓►i/ 'i Date of Birth: HZ 7 3 Social Security Number: Address: Employee's Signature: Sex Phone Number: STATE OF FLORIDA COUNTY OF PINELLAS Rev. 4/08 Form #9900 -0053 Date: cP/ S /i The fore. ='a instrument w. s ac�snQo4ledgedef9rp me this 5 (1 ey J !'T h C' /D�'pr.7I if, who is personally known to me or who has provided J as ide lQ� (Signs re) e�,d L- i d Notary Public Name of Notary Printed My CommissidtO7C -STATE OF FLORIDA ° Deborah L. Ford Commission # DD763426 •` Expires: MAY 15, 2012 BONDED THRU ATLANTIC BONDING CO., INC. File Name: Pension Entitlement Option Form Police & Fire n i Estimated Pension Worksheet John Horning LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 8/31/2011 5/20/1991 20.2806 Prepared by: Deborah Ford Date: 8/5/11 CALENDAR YEAR GROSS PENSION EARNINGS 2006 $69,314.15 2007 $75,288.50 2008 $76,654.89 2009 $84,744.60 2010 $82,599.61 $388,601.75 5/ $77,720.35 12/ $6,476.70 x 0.0275 x 20.2806 $3,612.15 Attachment number 1 Page 14 of 20 (5 Year Total) (Yearly Avg) (Monthly Avg) (Benefit Rate) (Yrs of Service) (Est Mtly Pension) City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors Police and Fire Members Only Employee Name: Employee Date of Birth: Marital Status: Spouse Date of Birth: Beneficiary Date of Birth: Benefit Commencement Date : John Horning 2 25 1966 m 11 17 1963 11 17 1963 9 1 2011 Estimated Monthly Normal Retirement Benefit: $3,612.15 05- Aug -11 sm clract03 Version: August 9, 2000 Actuarial Equivalent Adjustment Factors: J &S Annuity Life Annuity 10 Year Certain 50% J &S 67% J &S 75% J &S 100% J &S 1.00000 1.04849 1.04245 1.01832 1.00865 1.00388 0.98984 Attachment number 1 Page 15 of 20 Estimated Monthly Benefit $3,612.15 $3,787.30 $3,765.48 $3,678.33 $3,643.38 $3,626.16 $3,575.45 PREFERENCE #1 PREFERENCE #2 CITY OF CLEARWATER EMPLOYEES' SEPARATION PAY PREFERENCES 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. Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days Of 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 4,gcefrii nt numlber 1 begin the following month. Page 16 of 20 , an_ employee of the City o'f_ 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 # 01 • and wish my benefits to be calculated under this preference. Please use my leave in the following manner: Run Out vacation I Coo • 0 sick floaters bonus hours Lump Sum In 9, (3vacation 341' % q. sick floaters bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. WITNESSES: Revised 1/02 Form #9900 -0008 EMPLOYEE'S SIGNATURE SOCIAL SECURITY #: ADDRESS- PHONE: 1. DATE- 7/11/1/ File Name: Employee Separation Pay Pref Ter 1 CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM SWORN POLICE AND FIRE PERSONNEL Shc C011 r of Clearwater General Employees' PensiaaA'Ian. Job Classification: Department Benefits Date: Date of Birth: —Po (%rcL V (C.e✓ s— ly`jgo 8- h. Isc. do hereby apply for retirement under the City Division - Date of Hire- 51I'// 0. Resignation Date- l` ld 6 it / Spouse's Name- l n I c�L - r�'�'►rcut4 Spouse's Date of Birth: al 11�C. 0 J Sex: me Sex: 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 Attachment num Page 17 of 20 The City of Clearwater Employees' Pension Plan provides multiple options to Plan Participants as to the manner of the pension benefit payment O tIIOn 1-Ge1ow 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 -I ife 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. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] Option 5 - 75% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his /her pension as long as he /she lives. If the Participant dies first, the beneficiary receives 75% of the pension for the rest of his /her life. If the beneficiary dies first, the Participant continues to receive 100% of his /her pension and upon his /her death, benefits cease. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] Option 6 - 100 %R .hint & Survival- _Annility - (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)1 Option 7 — 66 213% Joint & Survivor Annuity - (must designate a beneficiary) The Participant receives his /her pension as long as he /she lives. If the Participant dies first, the beneficiary receives 66 2/3% of the pension for the rest of his /her life. If the beneficiary dies first, the Participant continues to receive 100% of his /her pension and upon his /her death, benefits cease. The beneficiary can be changed at any time. [Section 2.398 (b) (2) (a) (3)] I have considered the normal form of benefit payment under such Plan (which is designated on this Form as Option 1) and the various altemative 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. ttachment number 1 Page 18 of 20 If taking Option 1 sign below: Option #: _L. Description: Joint and Survivor Annuity Employee's Signature: Date: Dependent children under the age of 48 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, 6, or 7 fill in beneficiary informati n and skin ,below: Description: / a o t n Option #: My deskated benefi ry is: Name: - ..Jora \ct iv`vtlj Social Security Number: Address: Employee's Signature: Date of Birth: , \ i l 1 L O STATE OF FLORIDA COUNTY OF PINELLAS Rev. 4/08 Form #9900 -0053 V ✓VI o.✓ Ant vi_ Se<ThiF Phone Number: Date: 7 // / 1/, The fore in instrument was c Jf'1 ''7/ /// by owledgeefore me this G ro,r).- - ev) raw/ who is personally known to me or who has provided as idenpa tior / -n� ho di (Sig ``ure) �- 1�, My Commission expires: NOTARY Notary Public Name of Notary Printed Deborah •P1DA L. Ford :Commission #DD763426 Expires: � AY 15 BONDED TURD A , 2012 Nameiiepi(ipeOption Form Police & Fire Estimated Pension Worksheet Sharon Imray LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 8/6/2011 5/14/1990 21.2278 Prepared by: Deborah Ford Date: 7/11/11 CALENDAR YEAR GROSS PENSION EARNINGS 2006 $61,947.89 2007 $65,092.08 2008 $67,960.43 2009 $72,024.96 2010 $71,974.15 $338,999,51_ 5/ $67,799.90 12/ $5,649.99 x 0.0275 x 21.2278 $3,298.26 Attachment number 1 Page 19 of 20 (5 Year Total) (Yearly Avg) (Monthly Avg) (Benefit Rate) (Yrs of Service) (Est Mtly Pension) City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors Police and Fire Members Only Employee Name: Employee Date of Birth: Marital Status: Spouse Date of Birth: Beneficiary Date of Birth: Benefit Commencement Date : Sharon Imray 8 6 1956 m 12 17 1960 12 17 1960 9 1 2011 Estimated Monthly Normal Retirement Benefit: $3,298.26 11-Jul-11 sm clract03 Version: August 9, 2000 Actuarial Equivalent Adjustment Factors: J &S Annuity Life Annuity 10 Year Certain 50% J &S 67% J &S 75% J &S 100% J &S 1.00000 1.09917 1.08332 1.03688 1.01766 1.00832 0.98128 Attachment number 1 Page 20 of 20 Estimated Monthly Benefit $-3,298.26 $3,625.36 $3,573.08 $3,419.92 $3,356.51 $3,325.69 $3,236.51 PREFERENCE #1 PREFERENCE #2 CITY OF CLEARWA TER EMPLOYEES' SEPARATION PAY PREFERENCES 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. 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 fin aJtFaVnO umber2 Termination date will be the final day of extended time. Pension ea- pefits2ovill begin the following month. Rar , 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 1 11-"0 sick floaters bonus hours 3 �' Co /vacation J C „3asick floaters 1 ljEi 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 A44 SOCIAL SECURITY #: WIT ESSES: ADDRESS- Revised 1/02 Form #9900 -0008 S{o ClkkoYv, 1J40f, C. 3 ,1(090 PHONE: 7 a--7 aS S— cL 4 DATE• % /1 1 File Name: Employee Separation Pay Pref CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM of Clearwater GenerCa nployees' Pension Plan. Job Classification: G-as J V e ru i' C o it Sex: 0M F Department j GCt S S. 1 Division: Benefits Dater if / it � - Date of Hire: 4l /1 19 Resignation Date: ► O 'p II Ora i kr1 do hereby apply for retirement under the City Spouse's Name: CC✓? +'n a._ Spouse's Date of Birth: /� /4 / O Sex: M Attachment ni Page 2 of 20 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)] mber 2 amber 2 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. [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 altemative 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 sign below: 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 AiCachment n Page 3 of 20 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: Description: 1 J`G 0/a 1,-iY- Su/Vi' ,/o, /1/1,)vi , Option #: My desigrrp�ted beneficiay is Name: Cbin ✓r► G- !tn/ pj Date of Birth: Social Security Number: _ - .,. Address: 5t, I elk /101,h tiUel, i‘O Sex Phone Number: a7 02(."4i- Employee's Signature: STATE OF FLORIDA COUNTY OF PINELLAS Rev. 4/08 Form #9900 -0009 Ar I►'cl ; PC 3Lf(90 Date: 7 / e f•"ri/o)— ing instrument was wledged before thi [ / / by /l Ct Y1 j i'�'1 . who is personally known to me or who has provided as identifi lion d who did /d. • not to dr gn''�) C. ; v-01 My Commission expires: N,:;.R'': Notary Public Name of Notary Printed Debc)rah L. t� c Comm % `I6 Ma 13, 21,12 File Name: Pension Entitlement Option Form Estimated Pension Worksheet Randy Holm LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 10/20/2011 6/11/1984 27.3583 Prepared by: Deborah Ford Date: 7/12/11 CALENDAR YEAR GROSS PENSION EARNINGS 2004 $54,184.43 2007 $56,075.55 2008 $56,551.91 2009 $53,892.59 2010 $56,883.73 $277,588.21 5/ $55,517.64 12/ $4,626.47 x 0.0275 x 27.3583 $3,480.74 Attachment number 2 Page 4 of 20 (5 Year Total) (Yearly Avg) (Monthly Avg) (Benefit Rate) (Yrs of Service) (Est Mtly Pension) City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors ESTIMATE Employee Name: Employee Date of Birth: Marital Status: Spouse Date of Birth: Beneficiary Date of Birth: Benefit Commencement Date Randy Holm 10 20 1956 m 12 4 1960 12 4 1960 : 11 1 2011 Estimated Monthly Normal Retirement Benefit: $3,480.74 Option 1 Option 2 Option 3 Option 4 Option 5 Option 6 12- Jul -11 sm clract01 Version: 1 -4 -96 Actuarial Equivalent Adjustment Factors: J &S Annuity Life Annuity 10 Year Certain 50% J &S 75% J &S 100% J &S ESTIMATE 1.00000 1.09612 1.08031 1.03400 1.00551 0.97855 Attachment number 2 Page 5 of 20 Estimated Monthly Benefit $3,480.74 $3,815.29 $3,760.28 $3,599.09 $3,499.92 $3,406.07 PREFERENCE #1 PREFERENCE #2 CITY OF CLEARWATER EMPLOYEES' SEPARATION PAY PREFERENCES 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. 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 �f'age6 of 20 i#iber 2 begin the following month. 1, /V I`ck l3U5SIIiaV) , 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 Li s= floaters ' bonus hours Lump Sum /3 4- to 3vacation `T � =' sick floaters � Cl - 0 bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. Revised 1/02 Form #9900 -0008 EMPLOYEE'S SIGNATURE SOCIAL SECURITY #- ADDRESS- PHONE: - _ uATE- File Name: Employee Separation Pay Pref CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM I, f(.) i C k l932 s S /'r1 a h . do hereby apply for retirement under the City of Clearwater General Employees' Pension Plan. f Job Classification: i01 l' (-'- C7O✓✓)vnU✓� r ‘Cc li area cipevuto/Sex:�F Department: Po % "c-C Division: Benefits Date: j / is d Date of Hire: 61-1.01e9. Date of Birth: /ola`sr75 3 Resignation Date: 9' a .3/// Spouse's Name: \oc GL. H. ae_s- S' m a 1'7 Sex: M Spouse's Date of Birth: S-7 Attachment ni mber 2 Page 7 of 20 The type of pension for which 1 am applying is (check only one): V 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)] ember 2 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. [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 sign below: Option #: 1 Description: Joint and Survivor Annuitv Employee's Signature: Date: Dependent children under the age of 18 and residing in my household are: Child's Name Sex Date of Birth Attachment n Page 8 of 20 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 . nd si n below: Option #: to Description: O`'O d Ci a, My desiated benefiary is: Name: i i v,� "'► SSWDate of Birth: (o / /5..? / 5 Sex Social Security Number: Address: Employee's Signature: vt/ t 11•x: nnv, 19. Phone Number: _ STATE OF FLORIDA The foreg ing ins rument was acknowledged before me this S ins by /vrG {L S S vna 1.-) who is personally known to me or who has provided as identify tion -nd who •,. /di n• t- e,. -n oa COUNTY OF PINELLAS Notary Public ,? -h(Signature) / / 0 i'' 0..-A 1 — ✓u Name of Notary Printed My Commission expixe ,. a_ NOTARY PUBLIC -STATE OF Fr 0" --. r z Deborah L. F Deboi _`_ .z =Coa:mi:si #D D763426 i�'4II7.7115'Otl � �n „u�`L''R u' D%63'i26 1�Ril q eS: MAY 1 S, 2012 �r *�” A R i ONDgp FIE BONBnvG CO,, JNC Rev. 4/08 Form #9900 -0009 File Name: Pension Entitlement Option Form Estimated Pension Worksheet Nick Gossman LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 9/23/2011 1/18/1990 21.6806 Prepared by: Christine Schlerf Date: 7/15/11 CALENDAR YEAR GROSS PENSION EARNINGS 2006 $62,582.74 2007 $65,269.79 2008 $71,172.71 2009 $62,213.00 2010 $61,943.38 $323,181.62 5/ $64,636.32 12/ $5,386.36 x 0.0275 x 21.6806 $3,211.43 Attachment number 2 Page 9 of 20 (5 Year Total) (Yearly Avg) (Monthly Avg) (Benefit Rate) (Yrs of Service) (Est Mtly Pension) City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors ESTIMATE Employee Name: Employee Date of Birth: Marital Status: Spouse Date of Birth: Beneficiary Date of Birth: Benefit Commencement Date Nick Gossman 10 28 1953 m 6 15 1957 6 15 1957 : 10 1 2011 • Estimated Monthly Normal Retirement Benefit: $3,211.43 Option 1 Option 2 Option 3 Option 4 Option 5 Option 6 15-Jul-11 sm clract01 Version: 1-4 -96 Actuarial Equivalent Adjustment Factors: Normal Form Life Annuity 10 Year Certain 50% J &S 75% J &S 100% J &S ESTIMATE 1.00000 1.11235 1.09027 1.03937 1.00635 0.97537 Attachment number 2 Page 10 of 20 Estimated Monthly Benefit $3,211.43 $3,572.23 $3,501.32 $3,337.85 $3,231.83 $3,132.34 PREFERENCE #1 PREFERENCE #2 CITY OF CLEARWATER EMPLOYEES' SEPARATION PAY PREFERENCES 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. Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days Of appricable), 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. f Termination date will be the final day of extended time. Pension �tber 2 fffi1 begin the following month. l rc cci IL R rvc:h , an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. I hereby certify that I fully understand the preferences offered to me. I choose to retire using separation pay preference # 1 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 53 S° di vacation S-9 y' 31 sick floaters "(2 --5- bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. W NESS S: Revised 1/02 Form #9900 -0008 EMPLOYEE'S SIGNATURE- SOCIAL SECURITY #• AD ESS- 3 0 3 (1 Ovn CS - d1. IJCt,K �(r at eaiu)M -e(, EL 3 3 7�9 PHONE: -7a-1 01 DATE- -7 ! 1 h. File Name: Employee Separation Pay Pref I, n CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM do hereby apply for retirement under the City of Clearwater eral Employees' Pension Plan. Job Classification: ArL t n j m 4 Va eK Sex: M Department: En ; ce ri'n Division: Benefits Date: qr 15 o .4 Date of Hire: Q� S� O Date of Birth: (r . I I(, O Resignation Date: 9 /1S /// Spouse's Name: 3rh g Spouse's Date of Birth: `f I 'L1 S" 1 S7. Sex: G F Attachment nLmber 2 Page 12 of 20 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)] 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. [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 sign below: 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 Attachment nu Page 13 of 20 If taking Option 2 sign below: Option #: 2 Employee's Signature: escription: Life Annui Date: 7 / °Z9`1/ If taking Option 3, 4, 5, or 6 fill in beneficiary information and sign below: Option #: My designated beneficiary is: Name: Description: 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 foregoin instrument was acknowledged before e this 7 h-q foregoin by J ✓'4t «o( A- `s f w�j who is personally known to me or who has provided as ide catio , and who d._ /di• n, t e - oat i a(Sure) df L, 7 My Commission expires: NOTARYLICSTATE OF FLORIDA Deborah L. Ford Commission #DD763426 ' -' Expires: MAY 15, 2012 BONDED MU ATLANTIC BON\y]NG CO., iNC. Notary Public Name of Notary Printed File Name: Pension Entitlement Option Form mber 2 Estimated Pension Worksheet Tracey Bruch LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 9/15/2011 9/15/1980 31.0000 Prepared by: Deborah Ford Date: 7/29/11 CALENDAR YEAR GROSS PENSION EARNINGS 2006 $73,692.06 2007 $76,639.94 2008 $79,667.12 2009 $79,667.12 2010 $79,667.12 $389,333.36 5/ $77,866.67 12/ $6,488.89 x 0.0275 x 31.0000 $5,531.78 Attachment number 2 Page 14 of 20 (5 Year Total) (Yearly Avg) (Monthly Avg) (Benefit Rate) (Yrs of Service) (Est Mtly Pension) City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors 29- Jul -11 sm ESTIMATE clract0l Version: Employee Name: Tracey Bruch 1-4 -96 Employee Date of Birth: 6 21 1960 Marital Status: m Spouse Date of Birth: 4 18 1957 Beneficiary Date of Birth: 4 18 1957 Benefit Commencement Date : 8 1 2011 Estimated Monthly Normal Retirement Benefit: $5,531.78 Actuarial Equivalent Adjustment Factors: Attachment number 2 Page 15 of 20 Estimated Monthly Benefit Option 1 J &S Annuity 1.00000 $5,531.78 Option 2 Life Annuity 1.05774 $5,851.20 Option 3 10 Year Certain 1.04745 $5,794.26 Option 4 50% J &S 1.02090 $5,647.39 Option 5 75% J &S 1.00342 $5,550.72 Option 6 100% J &S 0.98654 $5,457.30 ESTIMATE PREFERENCE #1 PREFERENCE #2 CITY OF CLEARWATER EMPLOYEES' SEPARATION PAY PREFERENCES 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. Employee can extend termination date by part or all of the time due for vacation, floating holiday pay, sick leave incentive, bonus days Cif appticable), 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 k 6 0f pt 2TY riper 2 begin the following month. J hr► SchuS c, , an employee of the City of Clearwater, hereby apply for pension benefits under the City's Employees' Pension Plan. I hereby certify that l 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 aY0' 0 vacation c9 (5-' Y,65-sick floaters /°1-®'O bonus hours I understand that my preference cannot be changed once this form is signed and that my decision is irrevocable. TNESSES: Revised 1/02 Form #9900 -0008 EMPLOYEE'S SIGNATURE SOCIAL SECURITY #: DDRESS- % ! 1 S Mar- PHONE 70171 71Q 5,--(163(e, DATE- /---L y 5- 8- 3 bi File Name: Employee Separation Pay Pref CITY OF CLEARWATER PENSION ENTITLEMENT OPTION REQUEST FORM I,a hen cc_hus --e✓ of Clearwater General Employees' Pension Plan. Job Classification k)-1— 3 Oe r v' ,& Sex: 't Department: who I . /li 'I , 4-.'rs Division: Benefits Date: cJ �! / Date of Hire: 9 j�' ��' 1 Date of Birth: '1/i3 s 7 Resignation Date: V r // do hereby apply for retirement under the City Spouse's Name: Sex: Spouse's Date of Birth: _ Attachment nt Page 17 of 20 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)] mber 2 mber 2 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. [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 altemative 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 sign below: Option #: 1 Employee's Signature: y Description: Joint and Survivor Annuity Date: /.3 / %f. Dependent children under th age of 18 and residing in my household are: Child's Name Sex Date of Birth Attachment nu Page 18 of 20 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 COUNTY OF PINELLAS Rev. 4/08 Form #9900 -0009 The foregoing instrument was acknowledged (b�eforre me th's by 0-701,,, JGA VC / who is personally known to me or who has provided as identific n anti who did/ 'd not xak- a ;• oath. 1 v x0./0 of Notary Public Name of Notary Printed My Commission expires: NOTARY PUBLIC -STATE OF FLORIDA Deborah L. Ford Commission # DD763426 Expires: MAY 15, 2012 BONDED A T 1i�8 9Petision Entitlement Option Form THRU Estimated Pension Worksheet John Schuster LAST DATE PAID: BENEFITS DATE CREDITED SERVICE 9/8/2011 9/8/1981 30.0000 Prepared by: Deborah Ford Date: 8/3/11 CALENDAR YEAR GROSS PENSION EARNINGS 2006 $53,491.44 2007 $59,936.83 2008 $62,087.97 2009 $63,885.36 2010 $64,162.50 $303,564.10 5/ $60,712.82 12/ $5,059.40 x 0.0275 x 30.0000 $4,174.01 Attachment number 2 Page 19 of 20 (5 Year Total) (Yearly Avg) (Monthly Avg) (Benefit Rate) (Yrs of Service) (Est Mtly Pension) City of Clearwater Employees' Pension Plan Actuarial Equivalence Factors ESTIMATE Employee Name: John Schuster Employee Date of Birth: 9 13 1957 Marital Status: s Spouse Date of Birth: Beneficiary Date of Birth: 1 29 1963 Benefit Commencement Date : 10 1 2011 Estimated Monthly Normal Retirement Benefit: $4,174.01 Option 1 Option 2 Option 3 Option 4 Option 5 Option 6 03- Aug -11 sm clract01 Version: 1-4 -96 Actuarial Equivalent Adjustment Factors: J &S Annuity Life Annuity 10 Year Certain 50% J &S 75% J &S 100% J &S ESTIMATE 1.00000 1.00000 0.98696 0.94402 0.91831 0.89397 Attachment number 2 Page 20 of 20 Estimated Monthly Benefit $4,174.01 $4,174.01 $4,119.58 $3,940.33 $3,833.04 $3,731.43 Pension Trustees Agenda Council Chambers - City Hall Meeting Date:8 /29/2011 SUBJECT / RECOMMENDATION: Approve the request of employee Colleen Lau, Police Department, to vest her pension as provided by Section 2.397 of the Employees' Pension Plan. SUMMARY: Colleen Lau, Police Information Technician I, Police Department, was employed by the City on July 16, 2001, and began participating in the Pension Plan on that date. Ms. Lau terminated from City employment on July 15, 2011. The Employees' Pension Plan provides that should an employee cease to be an employee of the City of Clearwater or change status from full -time to part -time after completing ten or more years of creditable service (pension participation), such employee shall acquire a vested interest in the retirement benefits. Vested pension payments commence on the first of the month following the month in which the employee normally would have been eligible for retirement. Section 2.397) provides for normal retirement eligibility when a participant has reached age 55 and completed twenty years of credited service, has completed 30 years of credited service, or has reached age 65 and completed ten years of credited service. Ms. Lau would have completed at least 10 years of service and reached age 65 on November 6, 2015. Her pension will be effective December 1, 2015. Review Approval: Cover Memo APPLICATION FOR VESTED RIGHTS PENSION Go t tee h �a U , being a person leaving employment with the City of Clearwater, Florida, and having completed ten (10) or more years of credited service, such service having occurred during the period from (date of entry into Pension Plan) C%� 1,1 / GI o?o o / to (date of resignation or change of status) 7Lt l /S, a 6/1. hereby makes application to receive the vested rights pension provided For by the City Code of Ordinances. As such former employee, I understand the pension requested will be computed pursuant to the provisions of the City Code of Ordinance in effect on the date of resignation. I hereby further certify that my date of birth is Pe v e r1 er- c/ /9s-0 The date I will begin to receive my pension will be iCe Ch-) // al 0 /5 Attachment number 1 Page 1 of 1 Further, I additionally certify that I have made no application seeking to obtain a return of the contributions that I paid into the Pension Fund during the period of my employment set forth above, I have not been convicted of a felony during my period of employment, and I have not received any other type of pension from the City. x Signature Social Security Number 1 Iv CAes4c n �!' y oliCe• Department/Division a )f c>` c ✓�r�, bn 1 c1h1 Law) a..L. Job Classification STATE OF FLORIDA COUNTY OF PINELLAS Street Address ,PCuO PO -24t, Ft. y�373 City, State, Zip Co e The foregoing instrument was acknowledged before me this // day of VU�c' ,201L by Gd "f f ecn LG u who is personally know to me or who has provided as identification and who did /did not take an oath. Voctze PV Notary Public ✓'c A�41ame of Notary Printed My commission expires: NOTARY PUBLIC -STATE OF FLORIDA Deborah L. Ford Commission #DD763426 Expires: MAY 15, 2012 BONDED TUC ATLANTIC ROXDLNO CO,1NC 1117 Rev. 4/09 Vested Pension Form