11/13/20121. Call to Order
2. Approval of Minutes
PENSION TRUSTEES AGENDA
Location: Council Chambers - City Hall
Date: 11/13/2012- 1:00 PM
2.1 Approve the minutes of the October 15, 2012 Pension Trustees meeting as submitted in written
summation by the City Clerk.
� Attachments
3. Pension Trustee Items
3.1 Approve the request of the new hires for acceptance into the Pension Plan as listed.
� Attachments
3.2 Approve the request of employees William Connell of the Police Department, Sheila Waters—Borland of
the Police Department, Philip Biazzo of the Police Department, and Ruby Jackson of the Parks and
Recreation Department far a regular pension as provided by Sections 2.397 and 2.398 of the Employees'
Pension Plan.
� Attachments
3.3 Approve the request of employee Kenneth Szuba of the Gas Systems Department to vest his pension as
provided by Section 2.397 of the Employees'Pension Plan.
� Attachments
4. Other Business
5. Adjourn
Pension Trustees Agenda
Council Chambers — City Hall
SUBJECT / RECOMMENDATION:
Meeting Date:l l/13/2012
Approve the minutes of the October 15, 2012 Pension Trustees meeting as submitted in written summation by the City Clerk.
SUMMARY:
Review Approval:
Cover Memo
Item # 1
Attachment number 1 \nPage 1
TRUSTEES OF THE EMPLOYEES' PENSION FUND MEETING MINUTES
CITY OF CLEARWATER
"�.+^ A�'�'� � � �r � � r � � °� �
Present: Chair/Trustee George N. Cretekos, Trustee Paul Gibson, Trustee
Doreen Hock-DiPolito, Trustee Bill Jonson, and Trustee Jay E.
Polglaze.
Also Present: William B. Horne II - City Manager, Jill S. Silverboard - Assistant City
Manager, Rod Irwin - Assistant City Manager, Pamela K. Akin - City
Attorney, and Rosemarie Call - City Clerk.
To provide continuity for research, items are in agenda order although not
necessarily discussed in that order.
Unapproved
1. Call to Order — Chair Georqe N. Cretekos
�
The meeting was called to order at 1:45 p.m. at City Hall.
2. Approval of Minutes
.�
2.1 Approve the minutes of the September 18, 2012 Pension Trustees meetinq as
submitted in written summation by the Cit Cy Ierk.
Trustee Bill Jonson moved to approve the minutes of the September 18, 2012 Pension
Trustees meeting as submitted in written summation by the City Clerk. The motion was
duly seconded and carried unanimously.
3.
3.1
Pension Trustee Items
A�prove the request of the new hires for acceptance into the pension plan as
listed.
Pension
Name, Job. Class, and Dept./Div . Hire Date Eliq. Date
Raymond Hill, Field Service Rep, Customer Service
Steven Pierucci, Solid Waste Equip Oper, Solid Waste
Ben Brubaker, Rec Leader, Parks and Recreation
Jermaine Floyd, Solid Waste Equip Oper, Solid Waste
Terrell Smith, Solid Waste Equip Oper, Solid Waste
Ronald Gemsheim, Asst Chief Health Safety, Fire Dept
Pension Trustees 2012-10-15
07/30/2012
07/30/2012
07/30/2012
07/30/2012
07/30/2012
08/13/2012
07/30/2012
07/30/2012
07/30/2012
07/30/2012
07/30/2012
08/13/2012
Item # 1
Ronald Neuberger, Fire Inspector II, Fire Department 08/13/2012
Sandra McFarlin, Acct Clerk, General Services Dept 08/13/2012
Christopher Fischer, Survey Assistant, Engineering Dept 08/13/2012
Jacques Dixon, Parks Sts and Sidewlks, P and R Dept 08/13/2012
Sheryl Crutchfield, Rec Sup I, Parks and Rec Dept 08/13/2012
James Herberson, SW Equip Oper, Solid Waste Dept 08/13/2012
Alexander Swatzell, SW Worker, Solid Waste Dept 08/13/2012
Peter Szinger, SW Equip Operator, Solid Waste Dept 08/13/2012
Attachment number 1 \nPage 2
08/13/2012
08/13/2012
08/13/2012
08/13/2012
08/13/2012
08/ 13/2012
08/ 13/2012
08/13/2012
Trustee Doreen Hock-DiPolito moved to approve the request of the new hires for
acceptance into the pension plan as listed. The motion was duly seconded and carried
unanimously.
3.2 Approve the request of employees Cecil Rhodes of the Library/Central Services
Department and Frederick Broda of the Engineerinq/Parking System Department
for a regular pension as provided by Sections 2.397 and 2.398 of the Employees
Pension Plan. �
Cecil Rhodes, Library Assistant, Library/Central Services Department, was
employed by the City on August 5, 1982, and her pension service credit is
effective on that date. Her pension will be effective September 1, 2012. Based on
an average salary of approximately $33,354.75 per year over the past five years,
the formula for computing regular pensions, and Ms. Rhodes' selection of the
100% Joint and Survivor Annuity, this pension will approximate $27,566.04
annually.
Frederick Broda, Parking Technician, Engineering/Parking System Department,
was employed by the City on October 7, 2002, and his pension service credit is
effective on that date. His pension will be effective November 1, 2012. Based on
an average salary of approximately $30,343.82 per year over the past five years,
the formula for computing regular pension and Mr. Broda's selection of the 75%
Joint and Survivor Annuity, this pension will approximate $8,356.08 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. Ms. Rhodes qualifies under the thirty years of service criteria
and Mr. Broda qualifies under the age 65 and 10 years of service criteria.
Trustee Jay Polglaze moved to approve the request of employees Cecil Rhodes of the
Library/Central Services Department and Frederick Broda of the Engineering/Parking
Pension Trustees 2012-10-15 2
Item # 1
Attachment number 1 \nPage 3
System 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 Walter Miksza of the Gas S st� ems
Department; Roberto Felici of the Police Department; Harry Maisel III of the
Police Department; and Douglas Swartz of the Fire Department to vest their
pension as provided by Section 2.397 of the Employees Pension Plan.
Walter Miksza, Gas Specialist, Gas Systems Department, was employed by the
City on September 14, 1987, and began participating in the Pension Plan on that
date. Mr. Miksza terminated from City employment on December 28, 2012.
Roberto Felici, Police Sergeant, Police Department, was employed by the City on
March 7, 1994, and began participating in the Pension Plan on that date. Mr.
Felici terminated from City employment on August 16, 2012.
Harry Maisel III, Police Communication Operator, Police Department, was
employed by the City on March 31, 1986, and began participating in the Pension
Plan on that date. Mr. Maisel terminated from City employment on August 7,
2012.
Douglas Swartz, Fire Assistant Chief, Fire Department, was employed by the City
on September 24, 2001, and began participating in the Pension Plan on that date.
Mr. Swartz terminated from City employment on September 7, 2012.
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. Miksza would have completed at least 20 years of service
and will reach age 55 on June 12, 2013. His pension will be effective July 1, 2013.
Mr. Maisel III would have completed at least 20 years of service and will reach
age 55 on March 28, 2016. His pension will be effective April 1, 2016.
Section 2.397 also provides for normal retirement eligibility when a participant has
completed twenty years of credited service in a type of employment described as
Pension Trustees 2012-10-15
Item # 1
�
Attachment number 1 \nPage 4
hazardous duty and further specifically defines service as a Police Officer as
meeting the hazardous duty criteria.
Mr. Felici would have completed at least 20 years of service on March 7, 2014.
His pension will be effective April 1, 2014. Mr. Swartz would have completed at
least 20 years of service on September 24, 2021. His pension will be effective
October 1, 2021.
Trustee Paul Gibson moved to approve the request of employee Walter Miksza of the
Gas Systems Department; Roberto Felici of the Police Department; Harry Maisel III of
the Police Department; and Douglas Swartz of the Fire Department to vest their pension
as provided by Section 2.397 of the Employees Pension Plan. The motion was duly
seconded and carried unanimously.
4.
5.
Other Business — None.
Adjourn
The meeting was adjourned at 1:46 p.m.
Attest
City Clerk
Pension Trustees 2012-10-15
�
�..�
Chair
Employees' Pension Plan Trustees
4
Item # 1
Pension Trustees Agenda
Council Chambers — City Hall
SUBJECT / RECOMMENDATION:
Approve the request of the new hires for acceptance into the Pension Plan as listed.
SUMMARY:
Pension
Name, Job. Class, & Dept./Div. Hire Date Elig. Date
Greg Cornella, Gas Technician I, Gas Department 08/28/2012 08/28/2012
Joshua Clower, Personal Payroll Tech, Parks and Rec 08/28/2012 08/28/2012
Elizabeth Bayly, Recreation Specialist, Parks and Rec 08/28/2012 08/28/2012
Phillip Horne, Water Distribution Operator Trainee, PU 08/28/2012 08/28/2012
Jerry Dilley, Fleet Mechanic, Solid Waste/General Ser 08/27/2012 08/27/2012
David Hall, Solid Waste Equipment Operator, SW/GS 08/28/2012 08/28/2012
Ralph Saraceno, Bldg Construction Insp, Planning/DS 08/28/2012 08/28/2012
Beverly Ryland—Hinton, Police Infonnation Techniciai, PD 08/28/2012 08/28/2012
Bryant Blair, Field Service Rep, Customer Service Dept 09/04/2012 09/04/2012
Keith Bauer, Solid Waste Worker, SW Dept 09/10/2012 09/10/2012
Michael Kirn, Drafting and Mapping Tech, Engineering Dept 09/10/2012 09/10/2012
Jonathan Coker, Fleet Mechanic, Fleet Department 09/10/2012 09/l 0/2012
Matthew Burgett, Gas Technician I, Gas Department 09/10/2012 09/10/2012
Christopher Cleaver, Tradesworker, Parks and Recreation 09/17/2012 09/17/2012
Charlene Invino, Accounting Clerk, Fleet Department 09/17/2012 09/17/2012
Toby Malloy, Police Aide, Police Department 08/16/2010 09/24/2012*
Thomas J. Murphy, Marine Fac Oper, Marine and Aviation 03/10/2010 09/22/2012**
Robert Orner, Fleet Mechanic, SW/General Services 09/24/2012 09/24/2012
Meeting Date:ll/13/2012
*Employee was originally hired as a part time employee on 08/16/10. Changed to full time employee and pension eligible on 09/24/12.
**Employee was originally hired as a part time employee on 03/10/10. Changed to full time employment and pension eligible on 09/22/12.
Cover Memo
Item # 2
Review Approval:
Pension Trustees Agenda
Council Chambers — City Hall
Meeting Date:l l/13/2012
SUBJECT / RECOMMENDATION:
Approve the request of employees William Connell of the Police Department, Sheila Waters—Borland of tYe Police Department, Philip
Biazzo of the Police Department, and Ruby Jackson of the Parks and Recreation Department for a regular pension as provided by
Sections 2.397 and 2.398 of the Employees' Pension Plan.
SUMMARY:
William Connell, Police Officer, Police Department, was employed by the City on December 30, 1991, and his
pension service credit is effective on that date. His pension will be effective October 1, 2012.
Based on an average salary of approximately $72,704.52 per year over the past five years, the formula for computing
regular pensions, and Mr. Connells' selection of the 100% Joint and Survivor Annuity, this pension will approximate
$41,475.96 annually.
Sheila Waters-Borland, Police Sergeant, Police Depa�tment, was employed by the City on July 2, 1990, and her
pension service credit is effective on that date. Her pension will be effective October 1, 2012.
Based on an average salary of approximately $86,615.29 per year over the past five years, the formula for computing
regular pensions, and Ms. Waters-Borlands'selection of the 100% Joint and Survivor Annuity, this pension will approximate
$52,971.24 annually.
Philip Biazzo, Police Officer, Police Department, was employed by the City on October 5, 1992, and his pension
service credit is effective on that date. His pension will be effective November 1, 2012.
Based on an average salary of approximately $71,906.25 per year over the past five years, the formula for computing
regular pensions, and Mr. Biazzos' selection of the Life Annuity, this pension will approximate $39,663.84.32 annually.
Ruby Jackson, Parks Service Technician II, Parks and Recreation Department, was employed by the City on
June 3, 1985, and her pension service credit is effective on January 27, 1995. Her pension will be effective November
1, 2012.
Based on an average salary of approximately $30,343.82 per year over the past five years, the formula for computing
regular pension and Mr. Broda's selection of the 75% Joint and Survivor Annuity, this pension will approximate $18,767.88
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. Ms. Jackson qualifies under the age 65 and 10 years of service criteria.
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 Major, Police Sergeant, and Police Lieutenant as meeting the
hazardous duty criteria. Mr. Connell, Ms. Waters-Bo�land, and Mr. Biazzo qualify under the hazardous duty criteria.
Cover Memo
Item # 3
Review Approval:
���� �r�* �- rc��rcl�I.� s �'
i ca'y�
�'I �Y C]F �L€.d 1� fJ�,f.4 :�"��
ENIPL CJ YEES' SFP.4 f�A TfC�IV PA Y Pf; �FER,�NGES
PR,EF�REIUCE �7 Empfoyees c�n r�c�iWe � lurn� sum paym�nt far �racatiar�, floating hol;day pay,
sic�C lea�e i��centi�e, banus ei�ys {if ar�alicabfe}, and 1,f2 flf accrueci s�ck lear�e at
the t3me of se�»ration from the Csty. T1�er� wif1 be na d�ciuctiar� �c�r pensi�n
�rom [his lu�[� surn payme�t nor �^tirili t�ris am�u�t count �s e�rnings in t��
ca{r.�latir�n of the �aensian. The I�s� c�ay r�f ti�°�+ork v�rilE be the ternlinatian dat�
�nd pension benefits vvifl be�in the fol[Uw'sng month.
PRE�Eh'El'JGE �2 Erri�layee car, ex�end term�nation date b�r part r�r a11 �i tY�e ti[�e [�ue far
_ _ _ �r�c�t�s�ri�iaat�n� �i�ic�f�y-pay, sdc�C_ lea�e ir�cer�ti�+e. banu�ays -4if �ppt3�ab�el, -
�nci 1��' nf accruecl sick leave. Er�ployee rnay choas� to r�an out this tirr,e in
�ny manner. ��lance will be pai�l ir7 a�urr�;� sum �n err��lc�y�e's fis��f payrf-�eck.
Tesr��in�tian date U�i�i t�e th� fin�� day �f �xt�nrje�i tis��e. Pension benefits vvill
begon ta�� follauvinr� rrEOnt�.
_..� -�..
------��—
i, --°.,''v 4-- 1C�'�'°+�:�'�'�0`l�_ _ , an empic�y�e crfi the City �f Clearw�«:r, ��ereby ��a�Iy ��r
perisir��� �}��efits urder the City`s ti=rnplr�yees' Pen�i��r� Piari.
9 heret��j certify tl�wt I#�jll�� urlderstand tl7e prefer�:r�c:es off�.;�d tc� me. I�:r�«osc �o r�t.ire �_isinc� s�F��:r�t��r�
E���y F�r�ferer�ce i��--- —�rld �r�ish m�,� ber�efits to b� cUlculater; unc�er tF�i:; �re3ercnce. Pl�ase �_ase rny
!e���re in ti�e fr�llr��^Uing fT��flCl�'f:
HU�� CUT
�UiT1�3 Jl�i�
�acation
,��'� v��+ .,c��inn
s�e� floatPrs
�_� ����:.�ck � flnatcr:
�7C]f1LES �1C7U�S
�v�
� be�nus �oi�rs
I �,rci�.�: ��.�ncl th�at ��y prPfLren4:e canr�c�t he r.;-�zn�ed onc;� tF;is fos-�-r� is si�,net; ar��i that. r.�-��.-�ecisi�n is
.--� . �' �
m ,.�.
� �r.�;,�rC`.N.
W �?v1P'�_ �YEE`� SIC;i�I:�. I i_;R� _ _'" �` `!� - _.
�'
''�.+"�''Tf'J�SS�S:
� F�
.. .����.��._
�E,..i!��[7 1 r'�}�
�•:Ji�f7i .�yO,�j[7-�}V4J��i
5�7CIA? S�C;:_1F;;T1' -.
F,L]L�RESS: —
� �
PH��'JE:�-.
� , r ��7��. -__ �f � l J �
�ile PJam�: Ernoioyee Se�ara[ion ?ay Prei
c;.# i Y c�F �i FQRUVt`r �"`�R
PENSION ENTIiL�ME€�T OPTIQN REC�UEST FORM
SINQRN P[�LI�E AND F'IRE �ERSCiI�hC�L
I, ti'�; l iLi i:� t'1£1 L'�Vl�l� 1.1
of �le�rw�ter Ger�eral �mployses
P�nsion F'I�,n.
da hereby ap�ly far retiremeni under th� C�ry
Jab Classiiication: T�il[_.�._ '�-'.=�-t�( �4' _
be�ariment� ��-'��-�- - - Divisian: Y{�-f�G
Ben�fits �7ate: i� �� � paie of H�re: ��� °
D�te of Birfh:� � Resignatian Date: `� �-�
Spouse's i�ame: ^
5pouse's Dat� af Birth: ._
T�e type �� pension for whici� G ar� applying is (cheGk on6y ane};
�rr Reguiar Pension based an years of service
Jab-connected �isability Pensian
Nan-job-connected �3isability Pension
E�rl}+ R�tir�ment
Sex: � F
{]1 S`�+C� �—
�
_ Sex: M F�
The City of Clearyvater Esr���laye2s' Pensicn Pl�n provides rnultiple o,�tians to Plan P��#icipants as �a the r^anner of
'€i ic �ici 336G[7 benC�if �,�yii`b��lt. +��i�tEi�i 9 1 �i��GVJ i�pCe5Ei9iS i�'�� �idi i�aai c� ui r�a� � npl fGrm of retiEemcn� ��iitifi. '�i iv
other optionaf farms (#2 -#7} shall be cr�rnp�iter� ta �e the Actuarial Equiv��fent af the normal benefif.
7he raormal frarrn of retirement benefit s1�aG� k�e ��n anrnulty p�i� monthly far tl�e �ife c�� the Partici��nt, with a
1C}C�/o sur��•�or annuify paid monthly for a periad af five y�ars fallowing the d�ath af the P�rticip�nt to the
bene�ciary, pro�ided th�t fa�7o�Wing suc� fi�e-year period th� survivar annu'sty s�all be reds�cecJ to 5Q%, r�f tY�e
�riginal s�rvi��or �nn�:ify amouni, excepf th�t, if �reater for pofice c�fEicers and firefi�hters, the norma3 form of
�aenefi# shall �e an �nn�ity p�id manthiy far the life of t�e participant with 12� p�yrr�ents gtiaranteecf. [See
seciion 2,397 (a} (3) (A}] �he P�rki�i�ant's sun!iving spause receiues the desic�nated �mo�ni for the rest o�
hisl}�er life �r until he!she remarries. if no survi�rin� spo�se, dependent chi[dren under the ac�e of 18 sh�ll b�
deeme� to be the beneficiasy an�i r�c�i��e thP designaied arnount until the ac�e of 18. [Sectior� 2.397 (a} (3j
and S�ctiar� 2.398 (b) (1)j
���tnn 2 y Life Ann�itu
� I he P�r#icipant �eceives hislher pension as I�ng as 1;efshe lives. U�on t1-�e de�th of the ��rficipant, beneiits
�D ce�se. ��ect�on 2.398 fb) (2) [G) {1)�
�
�
�a�4;nn 'i � '�4 Y ar �"r� � LifP ,�nnuitv - (must designate a ben�ficiary}
The P�r�icipant rec�ives hislher pec�si�n �s lang as helsne li��es. ]f the Parti�ipant dies � r �2� ��anthfy
�ayments have b��n rnade, ti�P rerrsaininc� p� ym�nts �.ir� t�a the 12f) �aymenis are mad� ta his,'her beneticiary.
lf pay,nents to the beneficiary carnmence ar�d helshe dies laei��e th� tat�! of ��0 payments has beerr rnacie,
�he rPm��nder of the paymer�.s is paid ta the '�eneficia�y's esta�e. lf the first ben�ficiary �redece�ses �he
par'sci��nt, helshe m�y clesirnate a ne+sr �ez��ficiary. E; °�o b��efici�ry is alive at the _i;ne of #he p��ticip�nt's
deakh, the participanf's estate �vill b� �aid t�e �alan�e af the 12a paym�nts. [Sectiors 2.398 (bj �2) (a} (2}]
C7ntion �E - �0% „�4in & ��rvi�ar ,+�nn�vit� - jmusf �esig�at� a benefieiary}
The P�rttci�ant receives nislner p�nsi�n as Eong as helshe fives. If the Pa�ticipant di�s first; ine benefici�ry
�ecei�des �fl°I� oi the p�nsion iorthe G-est af his+'}+er li;�. If the ben�iici�ry di�s rirst, the Particip�r�t �ar�zinues Fa
receive 1 DD�io of hislher pensiort and upon hfs;'f�er d�a�h, benefits ce�se. T��� �ene�iciary can �e changed �t
any ti.r�e. [Seciic�n 2.398 (b) (2} �a} t3}j
c�n�ifln � - 7�°I� ,LQint & Survi�o�- Ann�it� � �r�ust ��sigrate � k��neficiar3"}
�he Partic��ant ree�ive� hislher r�ensi�n as loi-�g as he,'sne li�,res. lf the Participant dies �ir�s�, the b�ra�fciar!r
receives T5°I� of fhe �ension far the r�st of his+`;�er ]i�e. lf fhe k�eneficiary dies firsi, tne Par�icipa�t contrnu�s t�
recei�c 1 DO°Aa af hislner pension �n�i up�n nislher death; bene€iks cease. The be�efci�ry can b� chanr�e�J at
any �ime. [S�c.ifln 2.39� (ia} (z} �a} {3)]
Qn�inn r'+ �t'1i�°I inirl4 R. Stia-fri�nr Anniiit� - Ft?liiS� �2�3t n�#� a h��nPf�r•ianJ1
The P�rt�e;i�ant receives hisltier ��nsion as long �s helshe 9EVes. 9fi �he P�rtic;p�nt c#ies first, �he b�neficiary
rec�i�es 100°/o af fhe pension for tr7e rest of hislh�r li�e. lf the �e�efici�ry dies first, tf=e Pa�ticip�nt contir�ues
to recei�e `1 fl[}°l� t�T hislher per�s;[�n and upor� hisfher de�iE�, k�e:�efits ce�se. The beneficiary c�n be chaE�ged
� �t any time. f5ectian �.398 {b) (2J �a} �3)}
�ntion 7 6� 13% ,! ' [ AnnuitY -{must designaie a beneficrary)
The (��rticip�n# r�ceiv�s hss,'�er pensiar� as lonc� as helsl�e lives. If the'Participant caies first, the beneficiary
receives 6� 2,'3°/0 of the p�r�sio�i fc�r tl�e rest oi h;s,'her life. !f ihe benvfic�ary dies firsk, the P��ticipant
continues to receive 100°I� oT hislh��er �?ension �nd upfln ��slher d�ati�x bene�its c��se. i4�e ben�:fics�ry can he
ch�r�t�ed at any t's;ne. [5ection 2,398 (b) {2} {�} [3)]
f have consiciered ihe norrr3al form of b�nefit paysr�ent under such Pl�n (�vhich "ss designated an this Form as C��tir�n
� j�nd the various alternative o�tso!�al hene�it p�yment methocJs (Op�sorss 2 thrauc�h 7} un�er such Pl�n �nd t��v�
electeci tn receive my rets�e�n�nC henefts as indiG�ted helow. (�3ote: �piian seEection to be ir��ic�ted both by
Numk�er ar�d Descripiion.}
I understand that c�nce rny first pensic�n chec4c is recei�ed, my decision vn this option is irrevocat�le.
C)ptEOn 1 s2ctn
�j�}�On ff. � I�25GGI�3t101i: Inint anri �i �n�iVnr AI"1�lUl�
Er��soyer�'s Sic�rsatur�. �`�ie:
❑2C]EiiGP'�f childrr�r� under t���. ��e of 1€� �nd residinc� in my househ�ld �re:
�hilc�'s Pvarne S�x Date c�f �srth
If takiriq Q�ti�r� 2 siqn belairv:
�C)F�tirrn �: �.. Descriptit�n: ` f� iuit�f
Employe�'s Si�nature: -
7 fi
�r�ti�n �:
Q2SCription:
I Pv1y cies cf:�aied ber,efci�ty is:
� I��7�e �;t'� �`--.^��2=�'�.. . Dake c�T E�irii�: _
�, ��c.���: 5e�uriky Nun}I�er:.
,�'�;ress: — —
- _.s �_. _-� -���
Ern�'.r�yee' : ign�kure: ��_ - _.-3: _
r 4 ii�
STf;TE QF FL�RIDA
rC7kJf� 1 Y �� PINE�
A�fICH�Lf�� �C'�TC' '
� �w
s� �3C3iARY F�BL1C'
� .5Tr7i c fJ� FLJi�` '�'•
. .o �t'.DIl1BT]� �,����i �''.�:.
::€ t �res 5!?�iz: �
I <�':. =! h:J �
i Ofi?i ytf`�-�GJ��I-�1';'i�
� ate: _
Sex M �;
'�hane �umher: _
EJGI�
,�_ �;� : f �'
;� , , i �--
The rarPgoinr� instru�r�ent e�vas acknowleciqed beac�re me th�is
�°i�r'� ���1 i^' -I''�-'` �1f �.�_'rr' ��q";,-..r�r: �g1e','1i'L �ti'rf'a0 I�S
�C
❑ersc�n=�l'� kno�^L�n 4o me�r v���ho h�:s ;�rovsded
ficaiian a�sd �n�no daolC71�I 310t t2kE Gn �ath.
� �� �! X � r:� � �-�'1 �.1_��'�•_��
(Si �:��t��re}
Nc�Eary� pu:�lrc
�ame oi h�otur;u� Pr�nt�c�
i��iy Carrimissior� ex �ICI���,
u �� � i�FU��I�:'i3�LB�
�s°9`�.T� �F ��tJF�P{3�
. a �+'�P17� �����'�
^`�a� ?���i;� s:an �ni:ilen-��n� � ptir�n Forrri Police &�ire
Wiffiam Cannefl
I..AST aATE PAID:
BEhIEFITS DRTE
CREDITE[] SER1110E
�stimated P�ensivn Vlforksheet
9128l2D'f 2
1213{�1 � 991
2�.744�
� Pre�pared by: Gina Triest�
m
� date: 9l�f 12
�
w
GR�SS
CALE�IDA1� �'�NS�C]N
�'EAR EARNINGS
2f]O�r $�67,243.99
2Q08 $75,065.51
2�09 $73,999,�7
2f]10 $75,493.84
�011 $71,72{}.D1
$363,522.62 [5 Year Total}
5! $72,T04,52 tYearly Avg}
121 $B4O5f�.71 {Iv'lonthly Aug)
x 4.0275 (Benefit I�ate)
x 20.T444 �Yr� af 5�rvice}
$3i456.33 (Est Mtly P�nsion)
Gity of Clearwater Emplvy�es' P�nsion Plan
Actuarial Equivalence Fac#vrs
Roli�e �nd Fir� Members �nly
Ernployee Nam�:
Employse Date of Birth:
Marital Status:
Spous� Date vf Birth:
Beneficiary Da#e af Birth;
Benefit Commencemer�t �]�#e
INilliam Cannell
4 5 1962
M
1 14 1971
'f 'l� 19i1
1� 1 2L�12
�fi-Sep-12
sm
cl�act�3
'Versir�n:
August 9, 200(]
Estirnated Mc�nthly Nvrr�al Retirement genefit: $3,456.33
Actu�rial Equi�aleni Adjus�ment Fac#ars:
Normaf Form 1.QOOf��
Life Annuity 1.48G60
10 Year Certain �.�Q7703
5{�% J&S
�7°/a J&S
75°fa J&5
1.g31$A�
i�rZ[��.*7
1.f1Ofi47
� 1Q�°r`o J&5 0.�8233
�
�
w
Estim�ted
Manthly
Benefit
$3,455.33
$3,755.E5
$3,722.�fi
$3,5fi�.37
$3,5Q7.45
$3,478.79
�3,39�.25
GI� t.�� ���f'��C�1,�► I ��
EMPLUY�E�' SEPARATIDN PAY PREFEF�EI�CES
-:� �= _� �� �5
--:�� �-� /' �� -y i..£F ��LT S S C.+# ���
r � �
PRE�ER�ENGE ��i Err�playe�s can rec�ive a lump sum payr�neni for vacatian, fioaiing hal�day {�ay, sick
leav� i�centive, bQnus days (if ap�ticable}, and '�l2 c�f accrueci siek leave at th� time
of se��ratian frarn the City. There will �e nc� deductian f�r pension f�-�m th�s lump
s€am payment nor wilt this amau�+t couret as earnings in #he ealculation of the
per�sion. The last day a� work will be fhe terminatirn date and pension k�enefits wiil
begin the faliowin� mont�.
PREF�RENC� #2 Emplflyee �an eact�rrd fermination date by p�rt or al� af t�e tirr�e due far �acaiic�n,
floating holiday �ay, sick le�ve incentive, bonus d�ys [i# a�plicabfe}, and 112 of
ac�rued sie€� leave. Em�aloyee may choase to run c?u# this time in any n�anner.
Balance will be paid in a l�mp s€am on employe�'s fin�l �aych�ck. Terr��inatian r1�t�
wifE k�e the f�nal day of ext�nded time. �'er�sian �enefi#s ��i!! begin the fallowing
mnr�th.
�, ��?;Zr� �:��� s;.�.i.-..'4 x,,� ,�n empl�yee nf the City of Clearw�ter, hereby apply for pe��sion
benefits under the G�ty's �mplayees' Pensian Plan.
f herel�y certify that V fuily �nd�rstanr� the �referenee� a�fered to rr�e. I choc�se ta r�tire ��sing separ�tian pay
preferenc� ## '�..- and wish my b���fits to b� calcuEated un�er this prefer�nce. Pl�ase use my I�av� irr it�i
follo�uving rnanner:
Rii� C�ut
va�atio=� sick fiiaaters �onus hc�urs
Lump 5um ���b�.� � �acati��� '_`�`°..,_�,��ic€� ,�� floaters ��'" �anus hQUrs
I�r�cE�rstand that rny preference cann�t �e chanc�ed onc� this f�rm is signed and that my �ecision is
m
ir�rev�c��le. r— r ,
� F1VlF'�C�"���'� 51C1�fATURE.-�-->��.''/� / `,:'i�°�...r��
W � �.�,�.� .�
WET�IESSFS:
.__ ..., , 1r .
,�t
'8,*R�''i�-I�:°i- ��'; 7` ".��
S�CIA� S�CL�RITY #�:
A�QR�SS:
PHDf��:
❑ATE: :�r'r %':��r==
P.ea�ised 1?u2
Fc�rm �99G�J-GC��& � ile �Jam�: Em��oyee S��aratia�r Fay F'ref
c�T�r a� c��a�twar�R
PEN510N EP�TfTLEMEN� OPT1aN �ZEQUES� Ft7�i�+1
! , ,��1 �� 1 � � l l =' �ir%' { `} � � f` �f 1i�..Yi �,1
of Cl�arwater General Emplfly+°es' Pensian Pian.
do h�re�y apply ior reiirer�ent under the Ci�j
Job Classiricaiia `"]- . �. � Sex: M �
[�epa��mpnt: Y ` '. Di�rfsion: ��' i��f .. • � �=t°v� t� a._� �—�-�n
�enefits date: '7._�._ ��,r� � C7ate of Hire: � '� -�? _r' G� `
[7�te af Bi€th: F�essgnatEOn Qaie: �{,— �— �?
�p��isC's �i�me: _ � ��:c [�;,,K•;, —
Spo�se's �ate of Bsrth: ,� —
5�x: .fv'1� F
�he typ� of pension r`or which 9 arra applyirsg is (check onsy ar��J �
�
� Regui,ar PensF�n ��s�:� on y�ars or servic�
J�k�-canr,�ected Disabili±y PensioF�
Nar,-joh-cQi�rected Qs��ility Pensior� _
The C:it�r of Clc�rytat•ur Ernploy�es' Pe!�sian Pla:� ��ra�id�s rnuotip�e o��tia;n� t� F'fan P��ici��nts as to the manncr o�
t�� ae;�sior �ene=t ;��yment. �pti�n 1 beln��.� �er�?-esenks �h� st�r�c�ar�i or norn�al fa���n �; reti��r�ent �enefit. The
ot�e; optio��af fcr:�ris (#2 -��} shall Ue cnrnpute� k� b� the F;ctuari;�l Ecuiv�l��t �f tr�� non�r�al benefit.
� tior� � -.ioint and Surviwar �nr�uit
� ne norr��al far,77 �i r��irem�nt ��en°fit sha31 �e �n annuity paid morthly for th� lif� of th� P�rticipant, with a
1�+3��o sur��ivor �arinuity paid m�rt��!y fc�r ��ersc�d oT fiv� year1 fail�wi��y t;:e death �f khe p�rtscipant Tc� thP
b�nefici��y, �fOWIdEC� �it�� �GIfQ�:^dinc� sucn ii�de ye�r p�ricd �ne sur�riv�r anz,uity sf�ali �e re�Juced :� �a°/o of ��e
ori�iral surv�vor �nr��i�� an���uni. [See se�ti��r� %.3�? [�} (3} (Aij I h� Partici�art's survyviric� spousE r�r�i��rEs
ihre d�sia�sated �;�,�ount for kha res� cf hisl��er lii� �r aintil nelsh� ��marri�s. I€ r:�r s�rr�'ivin� spous�, ���encier�t
cr:il�rL� ur�der th� �ge Q: 18 s���als be cizeme�+ t� h� tf�e �enefc�ar� and rec�i�e tha Cesir�nat��' �mou�t �ntil
tl��e �qe uF 18. [52c�ion ?_.337 [a) �31 �r�r� Sect;crr� 2.3�8 (bj f 1 j]
�] tios� � - L.i�e �nnuit
� Ti�e Par��cipan� rec�ives ��islr,er pension as long us reishe lives. Ucan t}�e death of t�ie Pa�ici�ant, be:�e<<ts
� c�ase. ��e�tion ?.398 (i:�i l21 �,�) ��f l]
� y� �7,(
c��tson_3 - ;0 "�ear Ce�?airi � L��P �r��auitv - �mt-�s$ �1�sig���e C! dJ�iZLYICI�°7}
r'n� P.:�r:ici�ant r�ce;ves I�isr'ner �ension �s !o�;� �s ��c�5h� ii�,es, 1F tn2 Partici,�ant �i�s ��fa�° 1?� rncnthly
pay:r��n:s hav� �eeri mad�. ihL ren��inin� pa��irr:n:s �<p to �h�.�� 12� paVrnc�nts ar� m� d� :c� nis;'"��r benef:��iar �.
f��ymUr�is ta tr:e t��eiic��r; cnm;r,�c��e and �ersFi� �i�>s b�� r� 't�i� t�tGl of 12i� ��v��enis I��s ���en �ra�u.
ih� r�main�ler �i [f�� �a_Irn�r�t� is p�id tu ih2 �an�ii�������a' c5:c�iu. IT tfl2 ,irst ta�.nz <ci�R,� ��rzJcceas:5 ti?e
�arivi�a�t, f:-u.+'s�� �7;�y C�ES[qrl�[� � n�:��+�' b^����isciary. I� nr� ���zficiary is �li���e at k`r�e �im� ci ine partic:ip�n�'s
��'; a�n, the partic;p�nt's �stute �h�i'I �e �ai,� th� �:�lanr� oi The 1?�J p�yr���nts. �Se�:,iian 2.3a3 {b} l`�i �a) ���1
;f;�,i;�� � ° �4�o-�c „Q9fi't � '��'L7?�111��E' ,a€�!?i7liV � �3iil�S'i t��S?�i3�L° C rr2i�ei c. : 'ij+'}
�=�� Pa�tiui�a�t r�cai�v�s hiaih�r ��nsi�n �s I�ng a� h�,`sh� 'iies. Ir ti�� �urivi;�ant �'ies i,rs�, ��±e �e�e iciar,;�
r�c?i�des :���`�� ai'.ne p�nsia,� icr?h� res: oT hisif7zr li�c. I; th:: �anUr'ic`,��ry �icS fl]"St; ifl� Pa;ilGl;:73i'cT CJili;nGvs tc�
r���ive 1C�C��� �+ hi�,'hvr �en�ian un� UF��i� his,'h:erde�th, b�nv�its r�Gs�. jS�ct�or.2.�G3 ;rl (21 fa} ;3))
i]iJElG�i �J ��J`�%a .1OIfl$ �s �LFiViVc�i �TIIiLf[f - {iYi!]SY G'�'���il:aT.B � �E.'ii:i'[:92�''�+�
i f,,� °��'_�':�ant rece���,es hi��^er npns;�r� �s Ion� �s r:.,+she li�+es. IT �he P�rtici�ani di�s firs't, th� be��eficiary
; �c�i��re� ?�°/o �f the ren�:r�i� for the ��sf ��T his,'ner ;i;e. lf tf�� �eneficiary dies first, i�te °aric���nt c��n:inues t�
f°C21VE `:'r�°rc O� �:;� ;lE" ;1�n5fGr• �?1C� U�70f] �1;�++�lcr G����n, �cil�il�S CC�S�. [raEC`f�n �.�.-r1�r irj I��j ;�) (�11
Q�ion 6-`lOfl°I4 Jafni c� Survi�or Annuit -�r�ust designate a b�neticiar]'}
T�i� PartiClG�fit TEG�'}VPS hS51'h�r pensitin as �ang �s hel�he li�es. �f t6�e �articipa�t di�s first, �he be�efciary
�eceiv�s 1 a0°f� o� the p�nsian fflr tn� r�st oi hisli�er 13f�. 4f �he k�enefi�i�ry c�ies first, L�ZE P�f'�1GI[7�f1� Cb'fi�If�U°S
ta r�ceiv� i 0{]'/o c�f his,'her pens�on and up�r� hislher death, benefts ce�s�. [Sectian 2.398 (b) (2} �aj (3)]
I ha�r� considered th° norm�l `crm o� bene�t p�yrnent �r�c�r such �'l�n (G^t�hicn is �Psi�n�t�d on this �crrrr� as C7ption
i) and fhe vari��as alternative opticnal b�nefit paymen� m��he�ds (�ptions 2 through ra) �nder sUCh Fldn �r�d have
elected ta rec�ive my retirem�r�t ben�fits as inds���ed befo��r. (�lote: C�pticn selection ia be i�dicated both by
Numher �nd D�sGript�Qn-i
i understand that onc� my �irs� p�nsion check ys received, my decision flr� €his option is irre�rocable.
If taking Option 1 si
t�elc�w:
Jption #� 1 C�escriotion: _Joint and Sunri�rar Annuity
Em playee's Ss� natu rE: _ D�te:
i��p�ndPnt children ��r�d�r *; �e age �� 18 �nd residing sn rny �ousPh�ld ar�=
Ghsl�'� i�am:e S�x �ate �f Birtt7
!f fakipn f3ntic��? ? Si?n helow'
��ti��n �: 2 pescriptian: Lif� F�a�n�€
�r7�ploye�'s 5igrature:
If ta4sin� dpfion 3, �, �, �r 6 fili 6n oen�siciary infiaa-r�atican arad sic
I �JPti���� #: __�' — C�escription: , �',, �_ , .�, ,.; �.
fti�y des gnat�� ��neFiciary is:
�l�mef::�";c,,� �;' :�-.-� r�r.'�! `�.� _ [7ate nf Birth: – – -_ .
I _
;;�cEGk Secu�ity Numb�r. _._
,�.�Gress: --
__ _ _ �
�7�te: __�
n iaelow�:
5e�'"� �
Phone Number:
�..r.
, � : �
'� . , �y' f `�✓,;�', ;%
� , �,�" Y.,.; r. `•` y/ r�?� �c�L�_ �
�I'1��IJ�`v�-C�`� �I��f1�tLJrF�"=,� —�' �..�ss t �, — — ' ._— _ _—
- _�
�
�I h i E Or FLC7�1�,� The iorEgoii�g irisLrurnent •4v�s acknof��ledr�e� �zfc�r� me this
, ., ,
�'OUNTYC7F Fls`l��_LAS g� 1';� � ,: �{? r �i � �, : � ;. �Urf`o is
i � � h . �� __" 7 .
�P��j' i�!�c��ly' �I1O�Vi� LO IYI�C �JC L�'J�7� i I�C�-S .�'i`ro1��l.lrG'�
tiricati�rr an� v,+ho �sd�'did i��t :�k� a� natn.
r
, � n ',-✓ ..�r:;''`�.
s; ,'',!' . _'�f� '�r,!.�'���- -._. --
natur�a
1,`I!J CGf7iC111SS101I �X�i�85:
M4G�f�l�,� KU'���
��,1 c,'6g .:T
NC77ARY i�BLIC
Fcim �y�C��_�=+���g �r ` 5i,4iE Qr FL.URE��
;�-� ��r�� ��zo��a�
, t � ��sises �l�31201 �;
f'�OtGi'/ �L;�';fC
�I�{7l� Ji �oE2ry' Prf�ii�ra'
File Narr;e: P�::nsion �r�iitl�;mer�t Gpticn Fcr n
Sheila Wat�rs�Borland
LAST 'DATE PAIa:
BENEFI�'S aATE
GREDITE❑ SERIIICE
Estimated P�nsion Vlfvrkshee�
9l28l2i]12
7I211990
22.2389
� Prepared by: Lisa Gaodrich
m
� Date: 9114112
�
w
GROSS
CALEN�Af� PENSlC7fV
YEAF� L�A'�N1NGS
2[3D7 $83,183.14
20Q8 �87,5�5.52
��a9 $88,781.24
209[] $85,32�.17
2011 $8i,234.38
�433;Q7�6.45 (5 Ye�r Total}
51 �8fi,61 �.Z9 (Yearly Av9)
12J $7,217.94 {Monthly Avg}
x �.0�75 {��nefit Rate}
x 22.�389 [Yrs af Service}
$4,414,�7 �Est Mtly Pensianj
City af Clearwater Employees' Pensian Plarr
Actuarial Equivalence �actars
Pvlice and F�re Members anly
Ern�lc�y�e �Jame: Sheila Waters-B�rland
Empl�y�e Dat� of Birth: �1 26 �968
IVlarital 5tatus: m
Spouse Date of �irth: 2 12 � 950
Beneficiary Date af B�r�h: � 12 'f950
Benefit Comm�nc�m�nt Da#� : 10 1 2�12
14-Sep-12
sm
�Iract03
Versic�n:
August 9, 2QQ0
�stirnate�! Manthly Nvrmal Retirement Benefit: $4,414.�7 Estimated
m
�
�
w
....................................... M�nthly
Actuari�l Equivalent Adjustment Factors. Benefit
J&S An n u ity 1. C1f�0[}{3 $4,414.27
Life Annuity 1.(}17�2 $4,493.39
1� Y�ar Cert�in 1.D132� $4,47�.9�
"�0°Io J&S 1.C1[}732 $4,4�6.�7
fi7°Io J&S 1.[}0383 $4,431.1$
7�°/a J&5 1.�(�21(} $4,423.53
100°/4 J&S 4�.�3g6�3 $4,�00.72
GI �Y �F CL �A R V'4fA TE"!R
EMPLUYf,�S` SEPAfzATIfJN PA }� PREFERENCES
�����/
�? � o r.�r��.� c��c��
PR�FEf?ENCE ;��' Emplc�yee� c�:� rec�iue a lL�r-np sum pavrnenr far vacaEic�s�, fl�ati�� hc�iir�ay paY,
sicfc leav� ir�c�nti�re. �on�s days [o� apr9FCarle3, ar�d ��'� of �r.crued si��C l��Ue at
the ti;ne nf separ�tion fram t6�e Citv. There �nril4 �e €�n d�d�:etion f�r pension
from this lur,-�p s:�m payr-�ent r��� v�.aill tr�ss arnaun; c�o�r:t �s �arning5 in trZe
c�lculati�� o� �th� panssc�n. T}��; l�s� day Q{ wark vY.�i�l be i:F-;e termin�tir�n date
apcj ;�ensscn !�e�:efits �lvill begiri �he follt�v�ring mant}�.
P,�'�F�RE,rUGE �#2 Err��layPe c;a;� ekt�nd termir�atsan date by �art ar all of �Y�e time du� for
_ -- — --- �a�:atinr�, �tlaatin� ���� f�ay, Sic.�feave G�s�,er;�ive. E�or�us - a�� �a pl-icr; -�i�e.� __..
ara 112 of ac:���rue.d sick le�ve. trnplr�yPe n�ay c}�ac�se to ri�r� ��t thi� tir�e ir�
a�y rrianner. 6alGr�ce ;��i�l he ;�ai�i in a I�sm;� �u=� e�n em��lc�yce's fir�al paych�ck.
Termir�aTi��� �nte ��vIII �7P_. the fGna6 d��� af extes�rled tirne. P�nsior� }�er���iits �•,��ill
�,ee�in the folla�+vinr� mc�nt;�.
-- — - -----�.�-� — � _ — -
--� -
%' �-k , L.; {� �� E � �� �' , �n empl�y�e c� t'r�P �:itv a` �;iearw���er, ��rery d�;�iy «��
i, _— —�
�er�s,on henefit� u�d�r Lhe C4ty`s Em�:�loy��s` F'eris�nn 1'fan.
! IlG �;�'y. `��'-�'f'+� t�"'`:t � fU��'� �Jrl�?rSt�l"1=i Li� �i;t `��'f�C�S �`�7�'[�u 7�) fll��. � Cfli]JSE'. t;i �'.`10E: �_lSlilC� SE:�J�3rr�L1Di!
Gc3'J �rHi�fBnCE �.— � . aS1C� vUiSil �tV ��1�ei1tS i0 ��� C��CU����� Ltf1L�Er till5 �i"Ef2�E��Ga. 1��U��!� US� fit`�I
leave in th� fc�llo��;vs; �g r;�anner:
�u�i CJl1i
L��rn� Sum
�acation — sir.k — flr�atE3s _ -- bc�r>��s hUi.�rs
��' � � ?¢--�� � �_ �]t��1US ilOLlrS
� _ �,�e�cat.ion _��'f� sick fis�aier�
— ���f° `j�`� __ ` - •
�..�, t-: °f"' . _ _3
I�_,�:���.�.[st��nri tr;�}t rny pkeference canr,at o� c;;an�e� or�c�• this f��rm ks sic;n�d and i��t my d��isi�n is
�
�r.i ,:,�,��:'�Ir�. ,�� •
� �r.;;���i `s'= � _��. �' 1 '�.i'J'�E: � ���� �`�- �-�:��.�.�' —
W / �' �'�
s
�,+f11! � I•�����;��:
�/' ��- – � . ' �'��`� _..
/ � ��
Y.
,��,�s��:i „�.r,�a
� o r^ ., � �!70-0003
�!���I�-._ ._,-._ �._ ii � `..f � . .. -
�,[�CR�SS: .
PHUN�: —
�
7� 1-� —����-
Fil� f�zm�: Emp�oyee ����rr?iori Pay Frz�
CiTY C)F C�.EARWATER
P�hfSi(]�J �NTITLEM�NT �PTI{3N REQLJ�ST F{�RM
SW�URN POLIC�,4ND FIRE PEFt50NNEL
E, f�'+ tr '�r' ^, da hereby apply for retirernenf under th�e Ciky
of Cleanvat�r Gener�,l Employees' Pension Plan.
.]ob �Cfassificatio� , e' . t��� �� $ Sex: � �
aepartmenf: �1f,`r —_ �3uision. cc-�m��f _ _._
Benefits Date: �� –`�-- �� Date of Hire: I C� ��°–�� �
C7ate of Birfh: Resign�tion Qa#e: :!i.°
Spc�use's I�arne:
Snouse's bate of Birth:
Th ��ae af pension for whf�h f�m a�plyir�g is �check only one}:
Regular Pensian based on y�ars of service
Jab-car�neeted I�isai�ili#y Pesssion
�lon-job-c�nnected �]is�bility Pension
Early Retir�ement
Sex: M F
The City op �iearwaier Ernpioyees' ��nsion Plan proaicies m�iiiipie a.�tions to Plan �ar�icipurr�s as ia the manner �x
ihe pea�s�an ber�e��t payment. Uptian � befavv represents t�e s#andard �r normal farm af retirement benefit. Yhe
o#her aptlonal forrns �#2 -##7} shall be cor���sted tr� be t�e Actuaria! Equi�afent af fhe norrn�l benefit.
Os�tinn 1-.9�int and 5urvivor A�f�ui��
The normal form of retiremenf benefit sh�lE be �n ann�ity pai�i monthEy for the life af #}�e Partici,��nt, �viii� a
10(7°fo survivor a�nuity �aid mon�hly for a per3od af fue ye�rs follaw{ng the death af the P�f�4CIjJaCI# [fl �}��'
beneficiary, pravlded that f�flawis�g such five-year period the survivor anr�uity shal4 b� reduce�f to 5p°Io of th�
originaE suruivor �nnuity amaunt, �xce�t that, if greater far po{ice officers and firefighEers, the a�t�rm�l fanr� of
benefi# shall �e an annuity paid monthly fQr th� lifre of the parficipant with �2�1 payments guaranteed. [See
sectian �.39� {a} (3} (A}] �he Par�icipant's survi�ing spaus� ceceives the designaked amount far the rest o�
h�slher life or until helsh� rem�rries. [f no surviving spc��se, d�p�ndent children u�der the age c�f 18 sh�ll be
d�emed to k�� the beneficiary and rece�ve the design�ted ampunf until t1�� ac�e of � 8. [Sectfor� 2.337 {�] �3}
and sect�on 2.s�a {r�] ���1
C`i�tion ? - Llft'�4f1��f
� T�e Particip��t receives hislher pensipn �s lo�rg as i�efshe li+res. Upan the deatf� of #he P�rticipant, �enef;ts
cease. [S�ctio�7 2.398 (�} �2} ��) {� }]
�
•� °� -� =,°w'r,usx des:��at� � b�nef'sciary]
Th� Partici�ani receiv�s I�isli�er ��nsion �s I�r�y �s i��,�she lives. If the P�rti�i�ani r�i�s k�efo�� 120 mor�kf��y
pay�m°nts have be�r� made, the reGnairsing �aymEnts ��p to the 12Q pay�ments are ma�e �� hislher beneficiar���.
lf �ayrr�er�is to t�se beneficiar� can�mence �nd helshe dies �e�or� the tatai a� �2Q paytn2nts has bevn ;n�de,
the r�rriainde� of the �ay�menks is paid to t��e k�en�€ici�ry's estatv. If t}�e frst ben�:iciar�,r predeceases :f�e
��rtici�aant, helshe may desi�nate a new beneficiary. If no benefici�ry is aiive at the iime ❑f t�e participant's
death, t€�e pa3�icipant`S ESt�t2 4V;l1 be paid fre balance ai the 12p payments. [Sectian 2.398 (b} (2) [�} �2}]
C�,nt"son �l 5b°Ia l-�;rs� � S�nriv4r �tr�r�f�it� �(m�ast desi�n�t� a l��n�ficiary)
The f'a�:icipank r��ei��s €�isJher �ension �s I�ng �s helshe fiv�s. lf the P2�ticip�nt des ferst, t=;� beneeici�ry
rece�ves 5��� aF th� p�nsion `��Y the r-est �f h��!her 9i��. ff the beneficiary dies firstr t�P Pariici�ant cc�ntinues #!�
rec�ave 10��i5 of hislher per�sinn an� t� �or his,'I�er �eaf��, ben�fits ceasa. The t��n�f�ciz ry r�n t�� ci�anged at
any tirn�. �Seciion 2.398 tbj �2} {�} �3,1]
�"5 °� ion �i - ��% a�ir�� & S��rvi�ve�r An�t�iitr - �rr�a.��s �es[gr?�i� � �qnefieEa�y'}
�}�e Pa��icipant rec�i�es hislher p�nsiQrl as "sgnc� as h�elshe liv�s. �3 th� Pa�iicipanr di�s rirst, tr�� berseiici�na
�ec�ives 75°'0 �� the per�io� f�r trz�: r�st �f �islher lif�. lf the i��i�eiici�ry di�s rerst, ihe ���tici��r�t cor�tii�t,es �;1
�ecei�a�e ��}U°�c �� r��sfr,�r r�nsio�l and u�on �iislh7�; d�-:th, �en?�itv e,�a,�, 3 h� bun���icE�ry can be rr�ai�r����i ,�t
�fljl [li`C'le. l�2Cil�k� `C..��� ��1j ��} �d� ��lj
l7 tinn F.. 1 Eiflo,, .l i f R fiiirviwnr Anni iit+� - fmi�gt rlpglnnata ��ar�afiriaevl
�fhe Parti�i��nt recei�+es €�islher pension as forsc� as he{s��e fives_ �f the Par�icip�nt dies first, the beneficiary
rec�ives '�(}0°/a o# t�e pensic�n for the r�st �f hislF�er life. !fi the bene#iciary dies first, khe Past`seipar�� continues
to receiWe �flO�I� �f h�sli��r �ension and upon his!''r�er �ie�th, b�nefits �ease. Th� bene ici�ry can t�e ch�ng�d
at �r�y time. [sect�an 2.3�8 (b} (2) (a� (3��
Or�tion 7 6fi 213°/a .lnint &�zr�-viv�r Annt�it�r -�rnust design�te a�eneficiary)
The Pa�ticipant receives his;`her �er�sion �s �ang as her'she liwes. lf the Participant dies first, th� bene Gciary
receives 60 2i3°lfl of ih�e pes�sion fbr the rest c�f hisfher 9ife_ I� the ber�fECiary dies frsi, the Partics��r�t
continues ta rece�ve ��C]°10 of hislher �aensian and u�on hss!l�er �eakh, bene€its ceas�. The �enefici�ry can b�
chan�ed a# anytime. �Seetian 2.3�8 [b) (2} (a) (3}J
I h��e carsi�ee ed th� �sarmal fa�m nf �aersefit paymer�t under suc� Pfan ���+rhich is desigr�aferS �ar� this Fc�rm �s Qptia�
1 J�nd the v�riaus altern�tive optional benefit �ayr�ent methads {C]�ti�r�s 2 through 7) under such Plan �nd have
�lected to recei�e rny retirement ben�fits �s intiscated belQ�v. 4�lote: ❑pt§on seE��tian to be rndicat�d batn by
N{�m�er and Descri�tifln.}
I understand �hat vr��e rny first pensian ch�ck is recei�ed, my decision on thts optican is irre�acat�le.
Ifi taicin C} tion 1 si n below:
Q��tir�rt #: � Qescriptir�n: Enint anr� �E �rvivnr Ar�nu` � -
E:7�ploy�e's Si�nature: d�#�'
�ea�ndent Ghi��r��7 ur�der the age of 18 anc� t-esiding ir� rry ho�sehald are�
Chi!d's f�1�rr�e Sex Qate of Birth
if takir�q O�tion 2 sign �elaw:
�rJ?`on �: �..
�E������oy�e's Sign�tu; �:
Gpii.�ri ,�:
/ �'
P�:lv �s�sic�r,atec� bene�iciary is:
��r�2: _
�ncia: Securi�y� , J�mher:
�id�-PSS:
Ernp;oyfee's Signuture:
Descripiion: 1 i�� Anniiit�, _
U�.scri�iio�:
❑ate of 8i��kh:
�c3t2: _ �� ����� �
Sex i�� �
Phorie Nurnb�r.
Daie:
STE;TE C?� FLDRl�7A �hefor�going instrument+,v�s acknotivledged k�efore m� i��is
U��Uf�JT�` �;�F �iN�! L,�S ,-,? i.��: c�f-•� i� � �;r �'�'�� r�„ � �_ - -�.°, �:f•h:� is
r "��_�r s %' {i'rr`7r�'�,r�- a,�. .R� , �1;1,.'��.�:�
�,�rson�;ly kntal���n to m� or wz�n has pro�+ide� �f - �� ` �
�:s id�ntific�ti�n and whn tii�idirJ no't :akP an o�th.
[�lot�:r� Public
;:=' � � -, a'��" �
-- �+^�iT�R � �i?�.i�;:
�,�.n.-r_-- -. __.�. Narr� af n�otary Pris�t�d
1�r1y Cc�mmissEnn e . a �rx�rr,## �E�a�SU�_
� $ ., �x�ir�� �i2����9 m
?av. =�o�
For;,� r-�+�i7D ��Ju � File PJarr,e: I�ensir,n Cr�ti;len�ent 7p�ir��;i Frrri�s �olie�v ;� Fir�
Philip Biaz�v
LAST DFITE PAI D:
SENEFITS DATE
�RECII�ED SEF2VI�E
Est�mated Pensian Wor�sheet
1012�12{712
� at�r� ���
20.[]583
�
m
� Pre��r�d b�: Michelle Kutch
�
w aate: 912711 �
GR�]SS
CALE�fDAR PENSfOh!
YEAF� EARN9h;GS
�or�� ��s,oa�.a�
24{l9 $85,583.1 �
2J10 $72,243.D4
2Q'61 $73,884.Q2
per maggie $�5,496.07 frQm 2Q1�
and $12,317.99 far 3 months from
�� �� �77:s�.;.a� zaa7)
$359,531.2i �5 Year Total}
51 �71;9a5.:25 �Yearly A�9�
12� ��,992.19 �Mc�nthly A�g}
x O.C}275 �Benefit Rate)
x 2D.0583 4Yrs of Service)
$3,3�05.32 jEst Mtfy Pension)
G�ty of C�earrrvater Emplvy�es' F'ensian Plan
Actuariai Equi�alence F�ctars
Police and Fire Members �nly
Em�ioyee Name: Phi�ip Bi�zzo
Empioy�� Date ot Birth: 9�� 196�
Marital Status: s
Spous� Qate �f Birth:
�en�;ficiary Da#e af Birth: 11 29 1951
B�n�;fit Cc�rr�mencemen� Date : 'E 1 1�fl 12
27-��ep-12
srn
clrac€03
V�rsion:
R�agusfi 9, 2D0�
Estim�ted Mart�hly Narmal Retirement Benefit: $3,3fl5.32 Estimated
....................................... �onthly
Actuarial Equ�v�fient Adjustment Factars: 8enefit
Normal Farrn 1.�flC3[3{� $3,305.3�
Lf�e Ann�ity 1.{�Q723 $3,329.22
� 0 Year C�r#ain 1.D��1�0 $3,3�?�.32
5a°/a J&� 0.98935 �3,2iQ.1C?
67°/a .i$SS �.9835� $3,25�.$6
7�°/v J$�S [�.98�}64 $3,�41.32
� � aa�,�n .��5 (J.97208 �3,�13.(}�
�
w
lc� yr� � c��� �S�
��TY �� �L���i'�VA°�ER
EIUIPL�3YE�S' SEPARATIU'� PAY PRE�'ERENCES
PREF�REI�CE #"I Emplayees can recei�e a lurnp surn p�y��r�� for vacatfon, flc�a�ing hc�liday pay, sick
leave i�centi�r�, bon�s days {if applicable}, an�{ �12 of acc�ued sick ieave �t the time
of s�para�ion frcam the City. There wil� be na dedu�tion far �er�sion fram this lump
sum payment nor wil� this ama�ant caunt as earnings in the calculatian o# the
pensian. The lasi c�ay af work will be th� #ermir��tion �{at� and pensian �aen��ts v�vifl
f�egin the �o3lowing man#h.
P��F�RE�ICE #2 Employee can exte�d ter�nination date by part or all Q� ��1� tIFTl� f�U@ fQ!' V���tl4f1,
filaaiing holid�y �ay, siek ieave incentive, k�onus cfays �if appl�c�ble}, �nd �12 rf
�accr�ed sick feave. �mpl�yee may chc��se to rura out this tirne ir� ar�y manner_
��lance will �e paEd in a lump sur� an empfoy��'s final paycheck. Termin�tion date
will be the final day of ex#end�d tirne. P��'ssi�n benefits vdil� 'begin tE�e follav,ring
month.
- —�_=:,:�_���-
�, �t,ti��.� �r�[':���C�✓L. , an empfoy�e of the City of Clearwater; hereby app6y far p�nsi+ar�
�
benefits under the City's Employe�s' Pension Plan.
I hereby eertify that i fully understand ihe p�efe��nces of�ered to rne. l chaose to retir� using separatiar� pay
preference # �- an� wish rny benefits to �e calcuf�ted �rnder thfs preferenc�. Pl��se use rny {�ave in th�
follawing manner:
F�ur� �7ut vac�tio� sick flaaters
Lump S��m :�'_��, `��C.����acatian ��--` � f���sick � i° iEaaters
bonus hou�s
� bor�us h�urs
I�.�nel�rst�rsd that my preferer�c� cannot b� ch��ged an�� this for€n is signed and that my decisiQn is
m
irr-ev�ca�le_ ,;.-� , !�t ,
� � f
�,, -��Pf�DYE� S SIGI�i�TUR�: °� ` �`-��—
� 41�� t°�-, ,, ;�-__ ��<-��'f.�-�—''�--�.
�- _ � , ,
„-
S�CI�,L SECURITY �:
Wl f N�SS�S: ADC3RESS: l���j �. !I[L�.���;.� �i.,__-����,.s? j�- �.��"�G� /`-�f�
� �i� _ � � `
�r`':.i�..�.�_ ����'"�� ��L��.�#'`r,t,,`�.��'.�"; �� _ -��� ��
.
F'H��i�: r���� ��LI" �'���� QATE:
Reu;s�� th�i2
Form ���C;C� UU��� File �farna: Emplayc� 5eparaii�r� ?ay Qr�;
� � ��
O� CjCC"3NJ2tRE' G
Jab Gl�ssifcation:
C7epafti�2r�t: �
8�nefits Date: t
Da�E O� Bli[i: �
C1TY C7� C��ARINATER
P�ENSIQN ENTIT�EMENT C}PTICJEJ R�QUEST �QRM
aE Employees' Pensian Plan.
�c���� �C? �v ac_� T
5p�ause's Narne: 1�
S�ouse's Da�e af Bir:fi��: �
do here�y a�ply fo� reiirernent und�r t�e �4ty
C)IVESEQlI:
❑ate af Fiira: �
i�es"sgnation �7ate:
Sex: M �
'° �'�%�'�` ' ,� j �� �
F L E`�
s�X: i+� F
; �-°
T':-ie typ� �f pe�siors for v�h;ch 1�m a�plyiny is �ch�ck oniy or��;:
� RequEar F'er�sion �ased ar� years �f service
,�o�-ccnn�UtGd Dis�hi!ity Pension
N�s�-jc�-ce�€�3�,°ctG�] l�is�bi;it�� Pension _�
i h� City af C;eanr��ter Empl�yees' f'ension �'��n �rravi�es mu,iiple c�ptions �o P1�3ra F'�rtici��nks as tr� ti�e rnanner �f
tt�e �ens�o� a�nef;t ��yr��ent. O�kion `1 �elow repr�sents kh� standarr� �r normal fia,m �'s reiirer��nL �enefEt. T��:
athe� optiona6 �orms (m2 - r6;1 sh�ll �e co�n��,ted ia be the Actuar;��l �qui;r�!en` of �he norrnal bGnefii.
C] iion 1- Jair�t �nd 5urvivor A�nnuit
Ts�° n�rmal -r�rm o� re�iremer�t b�nefit shall �e an anr�usty �a;d r�r�rithly #ar th� life af trie f'��icip��nt, wit� a
1�J��i� survavor �ri�ui�� p�i� monti�iy ror a��er;a� �i fi�r� ye��rs fa'slc�ti^r+n� ihe �e�tn e�f the F'ar�i�i��nt �o th�
bene`IC.aI j!; �C.�VIC�2{� �h�t :o31o�rJing such fivu y��r periad the s�n��v�; annuikV sh�ll ��e re�u��d tv 5f3°I� cf t'rt�
crEr�inal surv�vor �nn�_i�t�,+ ar�;�un`. [S�e sect�on 2.39� (�} (3} ;,�j] The Pa�icip�nt's survivi�g s�:ou�e r�cesves
the d�signat�d a,r�o�9nf Tor th� rest af f7is�'hPr liie ar tirkil he,'sh� rern�rries. If �o surviuinq s�ause: de�end�nt
chi',dr�n �inder the age of �8 sh�ll b� deemec� tc� �E the aene�ici�ry and r�veive t�e d�signat�:d arr�aunt urstil
��;e �ge ai � t�. [SFaction 2.397 !a} ; 3} and Sect:c�n 2.358 �b} �1;]
4�atior� 2 - Live Ann��
� The Par�cipant rece�ves hislt��r p�ns;�;� as lor�g �s h�isi�e lives. Up��n the deat}� o� tt�e F'arici��n#, benetits
� ;��se. [Sect;on 2.3�i8 (b} (Z1 (a) � � 11
,� +.,� �i�n 3 -'�Q `�ear �erai� � �iie �nr��ii�ty -,rru�i d�si�na_� � �er�eFic=a�Y}
"J! Z�h� °artic�=�unt r4ce�v�s hislher ��nsiat� as lonc� as he�'sh�: livrs If �f���� �articipan? aies b�fore 1�a :�onThCy
!�a1�f?lF�flt=: `r"1� Vr �iETI fT:a�2, �;'l�' fE�il�ICllflC� �J�!,+fT12�1t5 LJ�' i� til� 12� �3�3'�1�1E?'�S dfE' f;"lud2 f0 �1:51i1°f fJt^fi�llCl3i��.
Ir paymer•�ts io th� ��n�;ici�r,� cc:mm�r�c� and ��Plsn? �i�s ���o�� th�, t�+tal :�f 12� payP��nts t�as ���n m�de,
the remafnd��r a� tr�� paym�nis Es �Gid t;, �n� b�r�efi�ia�y's ?st:te. li ;h� fi��t rer:eFic=;Gry �r�c,'�ce���s ;};�
partici��nt h�is��e may �ipssgnate � n�;;v b��-iei'�e.iary. I; ��o benefic�ary is al'sv� Ut thu time ��� the paR;cip�ni's
�e�ih, ihe �ar�icipant's °state ��,�i!I be pai� zh� b�1�nce of ihe 32� p�yrr�ents. [Sectio�� 2.3�8 (b) �2} (ai f�}]
n "tsc�n 4 - 5�°r� J�inx � �izr�uivor ,�n�aui�y - �rz�ti�s� elesi�����ti a ��r��.�i�ia�-y}
Tree Par�icipant re�.:wi��es hislher ;�en�ion �s la�g as nW,�she li�.+es !i tl��� ���tici;�anr ds�s first, 'the b���eficia,�r
Ce:C21VeS �'�".�a ❑f {flE? ��2fiSlC�sl i0f i:t? f�5� �T fliS?�lvr �li�. �i the b�n�il��l3� y� �IG� il�St, til2 �cf ilCl���€� �Gf"rtlilU�.S �Q
r�c�3v� 1 G��°� o� hisl'h�r �ensian ar,d upQ�� hielhar de�ih, ben�r"i'ts ce�se. [Sec;ti�r 2.;��J8 ;bj l2j {�i 1,3)]
ti tics�� � - 7�°Ip Joint i� Survivor �nr�uii - ��r��s� �°si�n��e � �a�r;e�=c�a>�i
s ne �ar�ic;part recei�,r�� ��slh�r p�ns;cr �s long as helshe lives. !f tn° �Qrttei�ant cJi�s �irs�, tn� be����i�'"sary
r�ceiv�s 75°Io �f t�e pension for tf�e rns�. c�; nislhe� liTe. If t�€e oFn�Yici�~u �!ies fis�st, th� Partiri��nt c��nt;n�.��s to
��ceid� � GO�� af hisl�s�r pension anJ u��: � hi�Jn�r �e�tr�, �Pr€eii:s c��sP. [Se�tior� 2..�9� �k�� �2 i(�} �3r1
O tic+n �-'?00%!�:r.t & Sun�ivor Ann�Eit -�m�rst ciesigr��ie � ber�eficiar]'�
�he P�nECipant receives }�islher pensian as lanc� as helsi�e li��es. If the P�rticip�r�t dies fiTSt, the �eneficiary
ree�lves 'Iflfl°lo bf the pensiQn for thw rest of hislher lif�. !f the �en�ficiary di�s �rst, t�e P�rtirip�n� �ontinues
io receive 1aa% af f�islher perrsion ar�d upon hislher d?��h, l�en�:fits ce�s�_ [Section 2.3�8 (b} (2) {al {3)]
I have cor,sidered the narma6 tarr� of b�ne�iti o�yxn�nt !�n��r su�;n Pla� (w�tic€� is �esign�ted �n �hss Fc��rn �s C}�tion
� j and the var;ous altern�tiv� op#ional henefst ��yFment rrekhods (�pti�ns 2 through 5} under such Plan �r�d hav�e
e;ect�d kc� receive my retiremenk �ene�its as indicated �ekov�. (iVate: Option selection to �� indi�ated batf� �;�
h�urnk�e�and [7es�r:ption.}
i�nderstand that onc� my fsrst pensivn check rs recei�recf, my de�isian Qn this �ptior� ss irre�a�at�lr�.
if taicin Q
Q�tian �: 1
'I siqn below:
EmNfoye�'s 5i�nak���:
`Jescription: �Join� and 5urviva� An�uit��
C]ependent chs�aren LindPr ihe ��� �f 18 an� residi�g in r-iy ho�.�sehald are
Chs�d's ��rr�� 5ex
�ate:
Date af Birth
�f i�Lj�� {�rr#inn "i Sl�ij�( g'1�?[7�; .,. -- - . —
�jp i�t r� #: _2 Des�ription: Life Anr�Uit�1.--
�rr�ploy��'s Si�r:at�re _ D�`e. - '
ifi �a�ci�Clption 3, �, �, or 6 fiilf in henerjc�ary infor�r-sa'ti�� ancf si�n b�lovv -
, , . r
� �7 •�. r�ptic�n ��' ����i �'' ['C ����s�� + .,i C �61b � i�i._� :?_�
[��7iiCaf} 7`�`: _,,;� _ Li"t'.,C !-
f��y desi�n�teJ �erefcia�,+ is:
N�rne: _���GL*�'�s.-r _ Gat2 of Sir#h_ ��,o�-i c t Sex� F --
�c C �c'c,�?v--, , ' } . \ [ c � . ;� r�
Sc�c�ak Sec-_�rit�, f��mk�er� � - P�one Nifmbar. � ;�i..�,1 ��.G�� `� � � J ,.�
4�S�re�s: ! �:"�� -� ,��r1[�-r�-r7�"� �G•L�'7�� x�--�'f'7G i'�t��c� , _�
- ; .. � �f .� ,.� � �
�' L:'.�.i,_,r'�+.�t.����'-� ) -,�L� r�"� � T � �_� .
i � �.I� I,�,i�"•- �i�C13tLi�ti:""rt^
�' � �
��
�fA � E C)r FLC�R4G�A
'�.C7�1N l"� GF P1N�LL_,''.5
/
-r�_�-- C73te: � 1�t 1,��
s f-�� i;�r��oi,��� Ir�sir�ment was ackn�wledge� bef;�re m� ihi�
�
='`��'�' S�� �Y �: I�7y ir_..� %.t 6.��, `.,���d`" L_ IPJ� I� IS
' F � `--�' _
�]Bi �'7f�ci��'J }:fl�J`�^!C� iQ f71e �f- V�Ji7� h�5 �'f�'VI�I v� :'�.��i, ?'v � r_? �,?!"Y7 �iL,{! ,
�,�'"°� No���ua��cstateofFi4,;�� �s id�n�ific�t:ar� an� wi�o cidldid s`lOLT2ifc �n oath.
���, Gina F"frieste '� ,,��,E�. _�� °�Iv � !`'`" _ NUt�i��l PL]b11G
"` My Commission EE 2D4342 (Signat�,re;
�xpiFeS OSl�312016 ' ,�
[���_ �J- • !��'� � �i�-�.. � h��me �i i�at�ry Printea
f��y �;�rr�n-iiss;c� �xp�r�s: '�P � � l ;�
���. �rca
f°crm �G9Gu-�7L�u9 ��Ic NamW: I'er�siUn �i�tit:err�ent fl�tior Form
Ruby Jacksan
�:�.��.�rr���,�i.�
BENEFITS DATE
CREDITE� S�RVECE
Esiimate�d Pensivn Worksheet
912812 Q 1 �
1J27J199�
17. �5�4
� Prepared by: Lisa GDOdrrch
m
� Qate: 9128112
�
w
GRCJSS
GALEI�C3f�R PENSIL7N
YEAR �A�ihJEhJGS
2Q07 $36,825.63
�ao� �ss,s5s.�o
20{}9 $39,�1 � 5.81
�01 p $39,431.ic�
�01 � `�38,790.�7
�193,12�.51 t5 Year Total)
�! $38,624.10 (Yearly Avg)
121 �3,218,68 {Monthly A�g�
x [}.(�275 (Benefit Rat�}
x 17.66�4 (Yrs of Service}
$'1,5�3.99 �Est M#ly Pensian]
C�ty of Clear�water Emplvy�es` Pens�on Plan
Actuarial Equirraience �'actors
ESTIIVIATE
Ernplay�� hlam�: Ruby Jacksan
Er-npl�y�e ❑ate of Birth: 9�7 1947
Marita! Status: s
�pQUSe a�te af �irth:
B�neficiary Date of Birth: $ �9 �981
Benefi# Commencemer�t Date :� 0 1 2CJ'� �
�stimatecl Monthly I�armal R�tirement B�nefit: '$1,��63.99
Optian 1
Qption 2
O�tion 3
�ptian 4
Optian 5
+Op#ian �
m
�
�
w
�8-5ep��2
�m
clractC31
�'ersic�n:
1-4-9�
Actuarial Equivalent Ac�justment Factors:
J&� Arwn�ity 1.0�}0(}t}
Life Annuity 1.00D0(�
� 0 Year Certain 0.95368
5D°/o .]&S D,8�306
75°Iti J$tS �.75�16
1'D4% J&S D.59932
ESTINIATE
Estimated
Mvnthly
6enefit
$i,5�3.�9
$1,5�3.99
$1,491.55
$1,287.��
'�1,�82.�3
$1,�93.�4
Pension Trustees Agenda
Council Chambers — City Hall
Meeting Date:l l/13/2012
SUBJECT / RECOMMENDATION:
Approve the request of employee Kenneth Szuba of the Gas Systems Department to vest his pension as provided by Section 2.397 of
the Employees'Pension Plan.
SUMMARY:
Kenneth Szuba, Gas Specialist, Gas Systems Department, was employed by the City on November 14, 1983, and began participating
in the Pension Plan on that date. Mr. Szuba will be terminated from City employment on December 28, 2012.
The Employees' Pension Plan provides that should an employee cease to be an employee of the Ciry of Clearwater or change status
from full—time to part—time after completing ten oanore 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. Szuba would
have completed at least 20 years of service and will reach age 55 on February 27, 2013. His pension will be effective March 1, 2013.
Review Approval:
Cover Memo
Item # 4
� �? %rS � G�c� � �
APPLICATIC)�V FOR VE�T�D RIGH�S PENSi�iV
'1'r�'_y�►t�'c��.. ��.-�,.,_�:... being a p�rsa� ie�ving empiaym�r�t with th�
Cjty of Clearwat�r, Florida, and having cc�mpletec� ten �1(]) c�r mc�re years of credited service,
such servic� having acc�rred during the periad from (date of enfry ir��c� Pension P�an)
3� ��; �o ��late of resignati�r� c�r change of status) :� ���j`.�
he by nnakes appiicati�n tQ rcc�ive the ves��d ri�hts �ensio� pr�v�ded fiQr by th� Gity Code caf
Drdinances. As such f�rm�r ern�iayee, I und�rstand the pension requesteci will be comp�ted
pursuan� t� the provisior�s af the City Cade �f �rdi€�ar��� in effect on tl�e dafe r�f resig��tiar�.
I here�y further certify that my d�te of birth is ,� �z-� ��
The date I will begin to receive my pension wi11 �e _ ��!�����
Furiher, I addi�ionally ce�tify khat I haue rnade n� application seeking ta obtain a return of the
cantributi�r�s that I paid into the Pens�an �und during the perioc{ c�f my emplayment ��� �orth
a�ove, I have not b�en eo�victed of a felany durEr�g my period of emp9c�yment, and I ha�e not
r¢�e;���d any ath�r typ� af per�v�an fr�rn s?�A �€t!{.
�`�--� .f� �
�; n atu re
9
' .e..yr �' '_''' � i V r� ;,! ; t-'� i'� .
�e�artmentJDivision
��� r� . � ���r : e=�8�.i 5 �
Jab Ciassification
�T�.TE �� FLC)RIaA
C�UNTY C]F PINELLAS
�
�
Social Security �I�m�er
.��[f 3k ,,�^�.
___'d� }' f �--' � �[ J `L�' � �-- 9 �fi �:.�f �� � �-Ef�
�treet Address
��� �` f: �'c.%c�� l �r � I=� � 1�� � '� ,� �'
Ci�y, Sta e, Zip C�cfe
The fr�regoing instrumen� wa� ackr�owlec#ged before
; ,-,
methis ' d�yof "i ,����
by �� �' 4�°� ��` i �`�'�.� ���1 ��'�
whc� i p rsanaliy kt�own tr me� r w�r� has prnvided
as identificatior�
������� and who d�dldid r�ot take ar� oa h.
�t������
�9ti'� ��� ���LIG {�j'�' j
�L.L�RI�}A 4 t l i�` ,��, ��`: �_ , 5 Oic� r]+' P u k] � E C
�. �s����# �.�aa�� � m
20
°�����g�° � pire�'�}2�► �� � ��,� ,��� l.� �`-�� .. of Notary Printed
My comrr�issir�n ex�ir�s: � .__��4-- � �
�lestecl °ension Fo;���
���. aios