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07/15/20131. Call to Order 2. Approval of Minutes PENSION TRUSTEES AGENDA Location: Council Chambers - City Hall Date: 7/15/2013- 1:00 PM 2.1 Approve the minutes of the June 18, 2013 Pension Trustees meeting as submitted in written summation by the City Clerk. � Attachments 3. Citizens to be Heard re Items Not on the Agenda 4. Pension Trustee Items 4.1 Approve the new hires for acceptance into the Pension Plan as listed. � Attachments 4.2 Approve the request of employee Cindy Ready of the Finance Department to vest her pension as provided by Section 2.419 of the Employees' Pension Plan. � Attachments 4.3 Approve the request of the following employees Mark Sena, Police Department; Norma Matthews, Parks and Recreation Department; Holly Ausanio, Library Department, and John Nuebel, Public Utilities for a regular pension as provided by Sections 2.416 and 2.424 of the Employees' Pension Plan. � Attachments 5. Other Business 6. Adjourn Pension Trustees Agenda Council Chambers — City Hall SUBJECT / RECOMMENDATION: Meeting Date:7/15/2013 Approve the minutes of the June 18, 2013 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� ii w`,1 �, �'I � "� � "I `��� 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 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. 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 9:50 a.m. at City H 2. Approval of Minutes 2.1 Approve the minutes of the May 13, 2013 Pension Trustees meeting as submitted in written summation by the City Clerk. Trustee Doreen Hock-DiPolito moved to approve the minutes of the May 13, 2013 Pension Trustees meeting as submitted in written summation by the City Clerk. The motion was duly seconded and carried unanimously. 3. 4. 4_1 Citizens to be Heard re Items Not on the Aqenda - None. Pension Trustee Items A�prove the request of the new hires for acceptance into the Pension Plan as listed. Pension Name, Job. Class, & Dept./Div. Hire Date Eliq. Date Shannon Hight, Fire Medic, Clwtr Fire and Rescue Dept Council6/18/2013 04/06/2013 04/06/2013 Item # 1 William Billups, Fire Medic, Clwtr Fire and Rescue Dept. Michael Remillet, Fire Medic, Clwtr Fire and Rescue Dept Elizabeth Pierce, Fire Medic, Clwtr Fire and Rescue Dept. 04/06/2013 04/06/2013 04/06/2013 Attachment number 1 \nPage 2 04/06/2013 04/06/2013 04/06/2013 James Desaulniers, Fire Medic, Clwtr Fire and Rescue Dept. 04/06/2013 04/06/2013 Justin Smith, Fire Medic, Clearwater Fire and Rescue Dept. 04/06/2013 04/06/2013 Justin Suhanovsky, Fire Medic, Clwtr Fire and Rescue Dept. Logan Cruz, Fire Medic, Clearwater Fire and Rescue Dept Yusupha Touroy, Stormwater Technician I, Engineering Dept Amanda Kirkpatrick, Rec Leader I, Parks and Rec Dept. Kelly Pierce, Police Comm Oper Trainee, Police Dept Daniel McKnight, Cust Service Rep, Customer Service Dept Korey Glass, Solid Waste Worker, Solid Waste Dept. Jesus Rolden Trejo, Tradesworker, General Services Dept. 04/06/2013 04/06/2013 04/06/2013 04/06/2013 04/06/2013 04/06/2013 04/06/2013 04/06/2013 04/22/2013 04/22/2013 04/22/2013 04/22/2013 04/22/2013 04/22/2013 04/22/2013 04/22/2013 Leviticus McKinnon, Sold Waste Worker, Solid Waste Dept. 04/22/2013 04/22/2013 � Trustee Jay Polglaze 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. 4.2 Approve the recommended pension plan expenditures for fiscal year 2014, totaling $321,000. The Employees' Pension Plan does not have a legally required annual budget. However, the Trustees must approve all expenditures. The following are routine expenditures that staff is requesting approval of for administrative efficiency. The recommended expenditures for fiscal year 2014 reflect an $11,000, or 3.3%, decrease from the fiscal year 2013 expenditures of $332,000. This decrease is primarily due to elimination of $15,000 included in the 2013 expenditures for the pension plan referendum. Training and travel are for the estimated costs of pension training and related Council6/18/2013 2 Item # 1 r Attachment number 1 \nPage 3 travel, including fiduciary training for the trustees and Pension Advisory Committee (PAC) members. This is a not-to-exceed amount given uncertainty regarding the number of trustees and PAC members that may elect to attend training conferences. Reimbursement to the General Fund is for the cost of oversight and administration of the Plan, recognized as revenue to the General Fund. The reimbursement is for services provided by Human Resources, Payroll, and Finance personnel. The firm of Klausner, Kaufman, Jensen and Levinson serves as the Plan's pension attorney. Annual attorney fees also include medical bills for medical services authorized by the PAC. Money manager, perFormance measurement consulting, safekeeping, and actuary fees are all governed by contracts separately approved by the Trustees, and are not included in this agenda item amount. Trustee Paul Gibson moved to approve the recommended pension plan expenditures for fiscal year 2014, totaling $321,000. The motion was duly seconded and carried unanimously. 4_3 Approve the request of the followinq employees Ozell George, Engineerinq Department; Marjorie Doucette, Finance Department; Robert Barry, Parks and Recreation and Brian Dewitt, Police Department; for a regular pension as arovided bv Sections 2.416 and 2.424 of the Emalovees Pension Plan. Ozell George, Stormwater Supervisor II, Engineering Department, was employed by the City on April 5, 1982 and his pension service credit is effective on that date. His pension will be effective June 1, 2013. Based on an average salary of approximately $67,937.31 per year over the past five years, the formula for computing regular pensions and Mr. George's selection of the 75% Joint and Survivor, this pension will approximate $45,747.12 annually. Marjorie Doucette, Payroll Services Manager, Finance Department, was employed by the City on June 24, 1985 and her pension service credit is effective on that date. Her pension will be effective July 1, 2013. Based on an average salary of approximately $75,443.52 per year over the past five years, the formula for computing regular pensions and Ms. Doucette's selection of the Joint and Survivor Annuity, this pension will approximate $62,258.16 annually. Robert Barry, Administrative Support Manager, Parks and Recreation Department, was employed by the City on September 24, 1979 and his pension service credit is effective on that date. His pension will be effective July 1, 2013. Based on an average salary of approximately $65,287.81 per year over the past Council6/18/2013 Item # 1 Attachment number 1 \nPage 4 five years, the formula for computing regular pensions and Mr. Barry's selection of the Joint and Survivor Annuity, this pension will approximate $60,615.24 annually. Brian Dewitt, Police Officer, Police Department was employed by the City on July 8, 1993 and his pension service credit is effective on that date. His pension will be effective August 1, 2013. Based on an average salary of approximately $72,963.19 per year over the past five years, the formula for computing regular pensions and Mr. Dewitt's selection of the 100% Joint and Survivor Annuity, this pension will approximate $39,569.28 annually. Section 2.416 provides for normal retirement eligibility for non-hazardous duty employees hired prior to the effective date of this reinstatement (January 1, 2013), a member shall be eligible for retirement following the earlier of the date on which a participant has reached the age of 55 years and completed twenty years of credited service; the date on which a participant has reached age sixty-five years and completed ten years of credited service; or the date on which a member has completed thirty years of service regardless of age. For non-hazardous duty employees hired on or after the effective date of this restatement, a member shall be eligible for retirement following the earlier of the date on which a participant has reached the age of sixty years and completed twenty-five years of credited service; or the date on which a participant has reached the age of sixty-five years and completed ten years of credited service. Mr. George, Ms. Doucette and Mr. Barry meet the non-hazardous duty criteria. Section 2.416 provides for normal retirement eligibility for hazardous duty employees, a member shall be eligible for retirement following the earlier of the date on which the participant has completed twenty years of credited service regardless of age, or the date on which the participant has reached fifty-five years and completed ten years of credited service. Mr. Dewitt meets the hazardous duty criteria. Trustee Bill Jonson moved to approve the request of the following employees Ozell George, Engineering Department; Marjorie Doucette, Finance Department; Robert Barry, Parks and Recreation and Brian Dewitt, Police Department; for a regular pension as provided by Sections 2.416 and 2.424 of the Employees Pension Plan. The motion was duly seconded and carried unanimously. 4.4 A�prove the request of employee Christopher L. Housholder of the Police Department to vest his pension as provided by Section 2.397 of the Employees Pension Plan. Christopher L. Housholder, Police Officer, Police Department, was employed by the City on April 29, 1996, and began participating in the Pension Plan on that date. Mr. Housholder terminated from City employment on April 10, 2013. Council6/18/2013 4 Item # 1 � Attachment number 1 \nPage 5 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 2.416 provides for hazardous duty normal retirement eligibility when a participant has completed twenty years of credited service regardless of their age, or the date on which the participant has reached the age of fifty-five years and completed ten years of credited service. Mr. Housholder would have completed at least 20 years of service on April 29, 2016. Trustee Jay Polglaze moved to approve the request of employee Christopher L. Housholder of the Police Department to vest his pension as provided by Section 2.397 of the Employees Pension Plan. The motion was duly seconded and carried unanimously. ! � 5. Other Business Finance Director Jay Ravins said recently approved state legislation requiring the disclosure of additional information of the City's pension plan. The disclosure must be submitted to the State annually. Additional disclosures include using a specific mortality table and impact of a 200-basis point decrease on the plan's interest rate assumption, requiring the actuary to provide an additional calculation based on a 5% return assumption. The mortality table required by the State is older than the one used currently by the plan, which is more current and conservative. Mr. Ravins said the additional disclosures have no impact on the Plan's funding or financial statements. 6. Adjourn The meeting adjourned at 10:00 a.m. � Attest City Clerk Council6/18/2013 � Chair Employees' Pension Plan Trustees Item # 1 Pension Trustees Agenda Council Chambers — City Hall SUBJECT / RECOMMENDATION: Approve the new hires for acceptance into the Pension Plan as listed. SUMMARY: Pension Name, Job. Class, & Dept./Div. Hire Date Elig. Date Kristina Cook, Accounting Clerlc, Finance Dept OS/06/2013 OS/06/2013 Peter Chaplinsky, PS Tech I, Parks and Rec Dept OS/06/2013 OS/06/2013 TaSheena Spearman, Eng Spec I, Eng/Stormwater Dept OS/13/2013 OS/13/2013 Andrew Hayslip, Planner II, Planning and Development Dept OS/18/2013 OS/18/2013 Randy O'Kelley, Bldg Const Inspec, Planning and Dev Dept OS/20/2013 OS/20/2013 James Benwell, Drafting and Mapping Technician, Eng Dept OS/20/2013 OS/20/2013 Review Approval: Meeting Date:7/15/2013 Cover Memo Item # 2 TO: FROM: SUBJECT: DATE: Pension Advisory Committee Joseph Roseto, Human Resources Director Recommendation for Acceptance into Pension Plan Attachment number 1 \nPage 1 ° earwater �� U Interoffice Correspondence Sheet SubjecURecommendation: Recommend approval of the new hires for acceptance into the Pension Plan as listed. Name, Job. Class, & Dept./Div. Hire Date Kristina Cook, Accounting Clerk, Finance Dept 05/06/2013 Peter Chaplinsky, Park Service Technician I, Parks and Recreation Dept 05/06/2013 TaSheena Spearman, Engineering Specialist I, Engineering/Stormwater Dept 05/13/2013 Andrew Hayslip, Planner II, Planning and Development Dept 05/18/2013 Randy O'Kelley, Bldg Construction Inspector, Planning and Development Dept 05/20/2013 James Benwell, Drafting and Mapping Technician, Engineering Dept 05/20/2013 Pension Elig. Date 05/06/2013 05/06/2013 05/13/2013 05/18/2013 05/20/2013 05/20/2013 Item # 2 Pension Trustees Agenda Council Chambers — City Hall Meeting Date:7/15/2013 SUBJECT / RECOMMENDATION: Approve the request of employee Cindy Ready of the Finance Department to vest her pension as provided by Section 2.419 of tbe Einployees' Pension Plan. SUMMARY: Cindy Ready, Accountant, Finance Department, was employed by the City on September 9, 2002, and began participating in the Pension Plan on that date. Ms. Ready will terminate from City employment on June 14, 2013. 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 2.416 provides for normal retirement eligibility for non—hazardous duty employees hired priorto the effective date of this reinstatement (1 /] /13), a member shall be eligible for retirement following the earlier of the date on which a participant has reached the age of 55 years and completed twenty (20) years of credited service; the date on which a participant has reached age sixty five (65) years and completed ten (10) years of credited service; or the date on which a member has completed thirty (30) years of service regardless of age. For non—hazardous duty employeeshired on or after the effective date of this restatement, a member shall be eligible for retirement following the earlier of the date on which a participant has reacbed the age of sixty (60) years and completed twenty five (25) years of credited service; or the date on which a participant has reached the age of sixty five (65) years and completed ten (10) years of credited service. Ms. Ready meet the non—lazardous duty criteria. Review Approval: Cover Memo Item # 3 APPL.ICAT�ON F�FZ V�STED FZiGHTS PEl�##510hJ �J� f` '�, �eing a p�rsan �eaV�n� �mpiaymer�t wiih tf�e '�� I�l_ �i ,t_,•�` � !�I � �" L� C�ty �f Clearv�a#er, FlarEC�; ar�d having cc�mpfeted ten {10� or ��ore years af credi#ed servrce, SUGi SE:�J1Ce having oc�urred �urir�g t}�e pericad from �date af e�try �nfio Penston Plan} r� ' � ? �C3 C���� D� I"F'SI 'flc��l(7!1 flC C�121f°EC�E �� S`�c`�fLtS} �: %{/����i�.:� - �, ; �'C;�T:-' f %r�:� ' `%-,��� r � � he �by rnakes application �Q ��cei�ve tfi�e vested rights pensian �rc�vid��! fQr by the City Gode of �rdinar�ce�s. .As �ucf� former emp�oy�e, I underst�nc� the �ension re��e�teci wi11 be compufed purs��n� to �he �rovisians o� ��e City Code of �7rdin�nce in �ffect r�n t}ie dafie Q� resigr��tian. I hereby furthe� c�rtify th�� my dat� of bFrth is .=rr;' Y.��Y�.,, rf,.��' �= �� �� �� The date I wi�1 begirr to recei�re my p�nsic�n vvilf b� � ��- C.� ,�i� i Further, I adciitianaliy certify that i h�ve mad� no application se�lcing to ob#a�r� a re��rn o� the cantributions that I paid into the Pension Fund d�ring th� �eriad of my em��aymen# set �o�th aba�e, l f�ave r�ot beer� convicted af ��elc�ny duri�g my per�od c�f empioyment= arrd f i�ave r�at r�v��v�� ar�y he� ±� w� �� ��r��i�n frarrm the Ci�;�. I�� I , ,� _ .6__+'VJ .. r+ ,� r �`,,1, 5ignatur� 1 , f � � r,� ' r � ,` � `'� `' �`� � �,- I' Y+�s ;�` ,�,�{ ; j�'� �� � t ❑epartm�ritlQiv�sian __ � �����` i��1�= ( � Job Glassification STRTE t�F FLC�RIDA C�JUNTY OF PlNELLAS � (,a �6�}���,LC i6EJi�F4 ��p,�� pl��3L4C ?l� -+STA,1'��F FLi�F�1fJ+� `;��,r �em# �'�20150�d w � ��res �12312�7�� Social Sec�r�ty i�,fumber �-(� ���''� J �,�„�r�%; tY � � lr � ,�,�'� � c. .l Sfreet Address 1._ f,,;t �,'��':r� � �-' �i � ���,�-j '�, � { Cify, State, Zip Cc�de The foregaing in5tru�nent was ackno�rviedc��d b�for� --, �+ , r� �7 �? m� this - day �f �` I' �� �� , ��pu�� ` � n ' f , J t� by _ , t ,� �. _ � �'.�� ; � whcr is p�rsanally k��wn ta me or vuh� has pro�rid�d c�- S If��il�iflCc`�fl�I"1 and wha di�fdid not take an c�at�. ;-, •� i',�,`, ';'�! - - ��';��i Nat�ry Public , � ��'?,��?�.;;�,; ,_"':,�-, %�;+� Name c�f �Jotary Prir�ted N!y commissit�n expEres: ��� ��: :-�'�:_-:.,� �.,'i,' 1i�s�ed °�nsion Farrr: Rev. �r0a SUBJECT / RECOMMENDATION: Pension Trustees Agenda Council Chambers — City Hall Meeting Date:7/15/2013 Approve the request of the following employees Mark Sena, Police Department Nonna Matthews, Parks and Recreation Department; Holly Ausanio, Library Department, and John Nuebel, Public Utilities for a regular pension as provided by Sections 2.416 and 2.424 of the Employees' Pension Plan. SUMMARY: Mark Sena, Police Offcer, Police Department, was employed by the City on August 15, 1988 and his pension service credit is effecrive on that date. His pension will be effective July 1, 2013. Based on an average salary of approximately $80,503.51 per year over the past five years, the formula for computing regular pensions and Mr. Sena's selection of the 100% Joint and Survivor, this pension will approximate $53,481.12 annually. Norma Matthews, Accounting Technician, Parks and Recreation Department, was employed by the City on September 21, 1992 and her pension service credit is effective on that date. Her pension will be effective July 1, 2013. Based on an average salary of approximately $36,469.29 per year over the past five years, the formula for computing regular pensions and Ms. Matthews' selection of the Life Annuity, this pension will approximate $23,421.12 annually. Holly Ausanio, Administrative Assistant, Library DeparYment, was employed by the City on February 10, 1986 and her pension service credit is effective on that date. Her pension will be effective July 1, 2013. Based on an average salary of approximately $55,313.39 per year over the past five years, the formula for computing regular pensions and Ms. Ausanio's selection of the Life Annuity, this pension will approximate $45,452.88 annually. John Nuebel, Wastewater Treatment Plant Operator A, Public Utilities, was employed by the City on October 26, 1987 and his pension service credit is effective on that date. His pension will be effecrive June 1, 2013. Based on an average salary of approximately $75,519.59 per year over the past 6ve years, the formula far computing regular pensions and Mr. Nuebel's selection of the Joint and Survivor Annuiry, this pension will approximate $53,160.00 annually. Stephanie Stefanelli, Parking Manager, Engineering Department, was employed by the Ciry on November 16, 1992 and her pension service credit is effective on that date. Her pension will be effective August 1, 2013. Based on an average salary of approximately $45,592.29 per year over the past five years, the formula far computing regular pensions and Ms. Stefanelli's selection of the 10 Year Certain and Life Annuiry, this pension will approximate $22,903.68 annually. Section 2.416 provides for normal retirement eligibility for non—hazardous duty employees hired priorto the effective date of this reinstatement (1/1/13), a member shall be eligible for retirement following the earlier of the date on which a participant has reached the age of 55 years and completed twenty (20) years of credited service; the date on which a participant has reached age sixty five (65) years and completed ten (10) years of credited service; or the date on which a member has completed thiriy (30) years of service regardless of age. For non—hazardous duty employees hired on or after the effective date of this restatement, a member shall be eligible far retirement following the earlier of the date on which a participant has reached the age of sixry (60) years and completed twenty five (25) years of credited service; ar the date on which a participant has reached the age of sixty five (65) years and completed ten (l0) years of credited service. Ms. Matthews, Ms. Ausanio, Mr. Nuebel, and Ms. Stefanelli have met the non—hazardous duty criteria. Section 2.416 provides for normal retirement eligibility for hazardous duty employees, a member shall be eligible for retirement following the earlier of the date on which the parricipant has completed twenty (20) years of credited service regardless of age, or the date on which the participant has reached fifty five (55) years and completed ten (10) years of credited service. Mr. Sena meets the hazardous duty criteria. Cover Memo Item # 4 Review Approval: �.� �����-� ���� ���� CiiY �iF �LEiirC`J1lATGr'� EMPL+C]Y�ES' SEFA�RATIQhI PAY RREFERENCES � �- :� � �i �� M��' C� 9 �D1� 4 9 �� _. PR��'�FtEN�E #1 �rnpfoyees can r�c�ive a lump sum paymer�t fDr uacation; flaair"��"'�i'i��a�pay,-sic4� leave incentive, bonus days tif applicai�le), and 11� Qf accrueci sick le��e �t the time of separafion from th� �ity. There wif{ lae nQ declUCtian fc�r p�nsion frtrrn this ]ump sum payment na� will this amaunt cr�unt as ear��ings in the calculat�an c�f the pension. The iast d�y af war4� vuifl be the terr�ination ciate ar�c! pensiQn benefis will �egin the folfowin� manth. PREFERENC� #2 Employee carr extend termirtatic�n d�te �y part or all af the �ime due far vacation, flt�atin� �oiiday pay, si�k leaue incent�ve, banus ci�ys �ifi applicable}, and �12 of accru�� sick lea�e. Empioyee rnay chaose tti run out this time in any m�nn�r. Bal�r�Ge vuili be paid ir� a lurr°tp s�m o�r emplay�e's �naf p�ych€�ck. Terrn��at�on dat� wif� be the final day a� extendecf tim�. Pensian benefits wilf begir� the fQllawing month. 9, Ga' ��-- , an emplc�y�� of th� City of CEearwater, her�bY �p�iy ft�r per�si�n i�enefits ur�der the City's Empiaye�s° Pensior� Pl�n. I h�rehy ce�tify that I fully understand the �areferences offered ta me. f ehaase ta r�tEre using s��aratior, �ay pr�ference #��— anci wish my benefits tt� be �alcuEat�d under this pref�rence. Please use my I�ave in the folfowing manner: Run �ut Lurnp Sum �J v�cation ;�.�} sick _.�' ^ ilaaters f ,� ;� , � � �iracation ;� � �:�� �S `� sick �� �aaters �_ �.� �� S, �� k]C3r�US I1{3UfS � � �� b� an _u�-� u rs �'�'�`./f —�— � � I ur�ierstand that rr�y preference eannat be c�ar�ged once fhis form is signed and that my decisipn is m irre�oeabfe. � � EMPl�.CaYE�'S SIGNATURE: _ _ % 1N17N�5SES: ��-==� ��--�-� SDC�AL SECURITI' #: AD�RESS: PNDNE: � ., f�ATE: _ , S �,f %��..� .. . ReWised 1ff72 , Forrn �990�-Oa�8 File �iame: EmplQyee Separation Pay Pre# C�TY .^�F �LE�9�W�TEl� PEtVSl�N �HTITLEMEI�T C7PTIC}N #�EQUEST FflRM HAZAR�DLJ� L']!!TY EIVIPLdYE� I, �u'� �tr�.' �C_i�G� _ da herebY ap�ly to receive benefits unc��r the City af Cl��rwa[er General EmPloyees' �ension Plan in �ccordance with the follawing [7ate c�f Birth: Jgb Classification: �LiC �� -i-rC-��Y' [�epartrnent: ���G� Dat� of H ire: �s ���� l`~`l' �'`� Benefits Ef#ee#i�re Dat�: � # r �(�� S pous�'s Name: �'�'1 i�' 1��� 5pause`s Date of Birth: �`�.�'14i.-. Gender (circle ane}: M} F C�ivisEOr�: L�c?'�.t�C:e C�a�e of Separatian: -ti-r� L � 17i.�i-r-i ��t Spouse's Gender �circl� c�n�}: M ihe iyp� of pensian far whic� ! am applying is (check anly ane}: +a/ Regular Pension b�sed an years of servic� Joka-connected [�isabilify Pension Non-jp�-cann�cied C�isability Pension The City of Glearwa#er Ernployees' Pension Plan provides muf#iple aptiorrs to Plars �'articipa�nts �s t� the rrr�nner �f the per�sian benefit p�yment. t�ptian 1 below represents the standard ar narmaE forrr� flf retirernent k�enefit. ihe other aptional forms {#2- #i} shall be carnp�ted to be the Actuarial Equivalent �f #he respective narm�[ benefif. �ptivn 1- Jvint anci 5urvsaor �4nnuity An annuity {aaid monthfy for the life of t'he Participant, with a 10D°lo survivqr annuity paid manthly for a period af five y�;�rs following the d�ath af the Particip�nt to the ben�fici�ry, pro�rided th�t ft�ilowing such five year periad the surviuor ann�iity shall be reduced ta 5{�°/� af the flrigir,af surviur�r ann�ity ar�aunt. [See section 2.397 (a} {3} {A)] The Par�icipant's surviving spnuse recei�es the designated amc�unt for the rest of hislher life or �r�til heJshe remarries. ff na sunriving spouse, dependent children under t'�e age af 18 shall be de�med ta be the beneficEary �ncf receive the designated amount until the �ge of 18. [Sectian �.397 {a} (3} and Sec#ian 2.398 (i�} (1 j] Q tio� 2-- L'o�e Anr�ui The Particspant rec�iv�es hislher pension as lar�� as helsh� fives. Upon #he d�ath of tihe Participant; ben�fits �e��e. �5ectic�n 2.416 �c} ar�d Section Z.424 �b) �2} a. 1.] m � tiQn 3-10 1°ear Certain & Life A��nuit -(must des�gna#e a beneficiaryj e Participant receiues hislher ,�ensiqn as IQng as helshe lives. €f the Participant dies befr�re 12{7 mortthiy pay�r-sents �ve been made, the remainQng paymen#s up fa the 12C7 payments are made tq hisfher beneficiary, or #he estate �f hislher beneficiary is nni alive. [5ectian 2.�24 �bj t2} a. �.� 4r�t�on 4- 50°Io Joint E� �urvi�vor A��uit - 4mus# t��signa4e � ber�efiiciarYj The �ariicipant �ecei�res h�s!her pension as iong as nelshe li�es- �f thae Participant dies firs#, fhe benefi�iary receives 50 percenk 4� the p�nsion fc�r the rest of the Iaeneficiary's life. If the bene�iciary dies first, €he Parkicip�nt m�y ekect anoth�r beneficiary or may continue tc� receiv� 1Q4°Io of hisfher pension �nd upor: hislher death, benefits cease. [Sectior� 2.424 �b} (2j a 3.] Q tivn 5- 75°/o Joint & 5€�rvivar Annui -(must designate a bene#iciary} The Panticipant rece�ves hislher pensir�n a� long as hefshe lives. If the Participant dies #irst, the beneficsary receives �5 percent of the pension for the rest of th� bene�ic€dry's fife. If thE �eneficia�r dies fFrst, th2 Pa�ieipant rnay �Eect anather beneficiary ar may caneinue to receiv� '6�J0°lo of hislher pension and upon hisll�er de�th, b�ne�its cease. [Sectior� 2.424 �b} [Zj a. 3.] Op#��on �6 - 14fl°/Q Joint & Survivor Annaaity -(must designate a beneficiaryj Th� P�rticipanf receives hislh�r p�nsian as IQng as helshe five�. If the Pa�ticipant dies first, the beneficiary receives 1 Qa percent af the pe�nsion for th� rss# of the bene€ieiary's life. lf the b�neficiary dies first, the PartiGip�nt rnay elecf another b�n�ficiary or may cQntinue ta re�e�ve �Q�4I6 of hislher pension and upon hislher death, benefifs cease. [Secti�n 2.424 (b] (2} a. 3,] Qption 7— 6� x/3°/a Join# & Survi�ar Annuity -�rr�ust designate a beneficiary) The PaRicipant receives hislher �ensian as lang as helshe lives. If ti�e �'a�ticipar�t di�s first, the ben�fieiary receives �6 �/3 percent of tFte pension for the rest �f the benefici�ry's life. ff the ben�fieiary dies first; the Participant may elect anather b�neficiary 4r may ec�ntinue fo recei�re 10Q'�/b �f hisiher pensian and upon hisfher death, henefits c�ase. [Sectiar? 2.424 (b} �2} a. 3.] Partia! Lump Sum Payment (�piian A partia] lump sum payment equal to either ten percent (��°'�}, �venty percent (20"/a), ar thirty percen# (3�J%4] af the actuarially determined value af th� normal retiresrrent benefEt due the memk�er may be elected in combination with any of the aptions indie�ted at�ove. If a member elects su�h a partial lump sum distributFon: then the monthiy retirement benefit for the option selected shal! be reduce� aceor�ingly thereafter. [S�ction 2.424 (b} (2} a. 4.] I have consid�red th�e various benefit payment metf�ods und�r such I'lan and have elected ta r�ce�ve my reiirement �enefits �s lndicat�d ��Ipw. ��lote: CJpkfon selection to be indicated bath by Number and aes�ription.} I understand that ance rrty farst p�r�sian ch�ck is recei�red, �ry decision an this opt�on is irreVOCable. 1T i8K4ClC� lJ�]LiOli °I S1C�T1 p@I�w: Qp#ian #: 1 Employee's Signature: i�escripfion: � Joint and Surviuor Annui�}r Daie: Cie�endent chilciren under the ag€: of 18 and resic�ing in rny hausehofd are: Child's Narne �ender Date of Birth If taking Optifln 2 sign i�el�w: dptian #: 2 �mplQy�e's 5ignature: taking Qpi pzion #: 3 n 3, fill in benefic My designated heneficiary is: hJame: aate a€ Birth: Addre�s: Pi�ane �lum�er: Employee's Sign�ture: ❑esCriptiarr: Life P,nnui ir�farmatio�s and siqr� be9ovu: Q�scrip#ion b�te: 10 Year Gertain and Life Anr�u Sacial Sec�rity Number; Gend�r {Circ€e C)ne} M F Qate: if iaking G��ic�n 4 Qptian #: '� r 7, �ip� �r aptwar �1�rnE��r, DG�:.ri,�tiflrs �nd ��er�f:��a, � in�c�r�rr��ter�:� �r�si Descrip#ifln� 1:�{;� %.�ointand 5s�r�i�orAnnuity My designated hene#iciary is: EV �me: ��__-� � �� J !` t t'� .� _ � �C' r'J y [�ate afi Birth: � Address: _ �� Phone Number: � Emplr�ye�'s Signature: _ ������- n ��9��: So�ial 5ecurity Number: _ __ _ �end�r �Cir�le C}ne) M �� �at�: J If faking a Partial Lump Swm F'a mer�t, fifl in Percerttage anc� sign below: C3ptic�n #: NA D�:scription: Partsal Lump Surn Paymer�t I elEet #a take a partial lump �um payrnent in the fallowing amouni (check anly c�ne�: 10°Ia a� the actu�rially determ�ned v�lue af fih� narmal retir�mer�t �enefit 20°�'0 �f the actuaria�ly determined v�lue of the r�ormal retir�ment benefit 3Q°/� of the actuarially determin�d value c�f the norma� retirement benefif I understand rr�y manthfy r�tirement be�e#it for the tsptian sekected a�ove shalk b� reduced aecordingly. �m�loy�e's Sign�ture: If namir�g a beroeficiary C}NL'�, fi�f in laenefi�ia My designated beneflciary is� Seneficiary Name: Bene�ciary Qate of Birfh: � 8eneficiary Address: Beneficiary PF�ane Nu€r�ber: Eonploy�e's Signatur�: i�ate: infvrmatian and sign b�low: � Ber�efi�iary Social 5ecu�ity #: �ene�ciary Gender (Circle C]ne} M F Date: � iF,TE C7F FLC]RIDA The fc�regoing instrument was acknowledger� ���or� me thss GflUNTY flF `�-�'_,� `�r� � , 1 "` '. _; -- da of �i�-����.�_: 2� � i�fNEL�.AS �. -� ;, �{ . �� ,��_`wr'a.'�;'�a•, _� r��.� ;r-�c.��_�. wha is persor��fly kn�wn ta rr�� or who has provid�d as i�entificaticrn and wF�o didldid nat tak� an o�th. } ,; � �,r,�� �ap�ry�ud��sta�eo�Fwr;aa ��,-.'.. ��-_ _� r-�, ��4w`t.t, _ �fcatary Public �, GjnB F 1�t3ESk� f iSignaturEj � �sycom�,��s�on�� zaa3ez = �, � -, �:: -� "��w. -� � �;��.�._- Name af I�otary Printed �qF�� Expirss 66f03l2fl76 My CQmmission expires: �-� �" `'� ��� --'�--''`,''� Rev. 04113 '�arm #99[7D-Cl[]Q9 File €�arr+e: PensiQt� Entitfement �ption Farm Ci i Y v� it�...?�.ytLtvvi� ��ri STATEM�I�T �� R�SIG�tAT4�J�V i, �����C'�- ,����"±s;�r -- , �mpfoyed as �C•"`l,t �'.- L��--hC-�-� in t�� �C�V.�� piv�sion af ��?�.1��. �, , �jrC� � �v't5'���-. -�-- pepartm�nt d[� hereby resign frt�m th2 senrice of t1�° Cit� af Cl�arwater. I request that thi� resignation b� t�uly acce�ted by rr�y ❑epa�tment Neacf and the Ap}�ointing Authariiy fc� �ecarr�e effecti�e �n �� � 9��� �� k_?� a � ,- _, .; �t '�'�'�t�G= ,(,�i��, AM PM. The reasnn for this resignation i� as fallows: _� �_ -° Retiremer�t on Ci�y pension. �rr�p€oyee's �ign�ture �EF,�RTIVlENT ACT1C3hl: Appr4ved by Divisic�n Head aivision H��d Gornments (C�ptianal} Approved by Departrr�ent H�ad Departrt�enf Head Cc�rnme�ts (Optional} �4��i� �F AP�'C]IIV�Ih]G Al1THDRITY � Daie sig€��d � � �� /', � 9 accept this �e�igna�ian to b�c�me e#f�ciive �n t}�e date and at t�e tirne snown a�ave: A�apcsintir�g Authority Appainting Authority Cornrnents {Optiona!} C�ate aate D ate 9MPORT�4Ni N�T�: The r�asv� fior this resign�tion must be shaw� in the space pr��i�ec�. The originaf farrn, wh�r� sign�d by �ne empiayee and �he divisi�n and departmer�t head, i� tQ be attached to the p�rsannel acifor� sheet an� fflrwarded to Hu�nan Re�ources. Persa�nel �ctiQn sheet mus� reflect ��e sta�us �f �ny Cify mani�s due tc� or by �his em�loy�� in acc�rdane� �nrit9� #h� Civii Ser�ice Rules and coli�ctive �argaining �gre�ments currently in effect. Revis�d 1196 Form ��901-fl�'14 File t�ame: State�n�n� of Resignat�an �'Ier��ber Data tzlan?�: I]ate of Sirtl� �'�ge at Rctir�izlet�� Seneficiary Data Na�Yae T]ate nf Birth A�e at ketii-einent Retirennent 17ata Ef ire i7ate Teri�linatic�n Uate Ef%c4iue I3ate f�.1C Coniril�iitiUns lIiCCICST C�tiy o� C;l��rwater ��nploy��es' Retirerrient �ysterr� Ben��zt lEsi�mate �rnRK 5�1��a 5l Y'ears 61�1onths 29 Ua_ys cr�Rxs�rrF SFh�, Sa�:ial S�curi�v No s���t�l s����,r� r�� 4$ Yea�'s +6 PvIo��tias 7 Davs Reldtio�shi� :�puuse. # �Fchilc�reil undi>r 13 : D fi$Ii51i988 Calculatior� Type � Esiimate t161�4,!2Q13 F3enefit Group � : Hazardaas - Grandfaihered 071011i013 F�etire�3lcnt "i'��?,:_,,. : Nc�rmal Retirernent � $U,5Q3.51 C��tie�n ,�lr,ct�d � D.O� t'art�h1`��iinp�iaa7� : �U.UO €;Q "lo} � O,f7U I'ot�LJ1!Ieirzber 5er�ice : 24 Years 9�Iaflihs i4 �7ays Fc�rt�iula fi�r Benefit A : 2.75�'/� ' 2�1.$3�16 v�ars * �. �;� °m� ��-, ��,,� � Fornt of Payrnci�t ,�, '�,��a�;�'�, T'actor Nnranal f�orm � _ I.(]f}f}[}{} Sin�le Li#e Annuity , �.� �,�' l.D'iQl 1 U'Ye�ir Cs:rt:aiti ar�[l I.i�e Ar�nuity p� � l.i]C 1�U ?f}°�U 7nint and Sur��i�or y ��-� 1.02{)� 1 6fi ?13��o Joint and SurviVC3r �° ,. 1.�C}412 ,5°,�, 7oirlt �nd St�n•i�or �'�.� f1.99f�14 1[?Oi�,.luint aa3d Suz�i�-�.�r '�;: C}.4729C� � m � � � Mvnkhly i3enefi� 7"u Nlrr��ber• 54,�€30.y2 54,915.3b ��,8G�.�7 $A,�i74.86 $4,599. i 4 ��,563.22 �4,456.7�i Potenti�l "I'o Beneficiary� 1�r A NiA T�1,'�1 �2,337.�3 53>Q6f.53 S3,�1?2.�? 54,�56.76 "T}-�� i�StEit� �i5plsi;c.�l a�ct ti,i ,ilu�t:ati� �,�urE,c ses i>nly anrl unle;5 c�.�rr€ivi��i��t�c's c?l},;:i��„s� ;hc,u(d rwc rrL' [I-(, iCi.C; �� t�i,al rrsuli�. � <.5 T11is calctdlatic�n �s s�ihj�ct lc� cc�a-rc�ti�n. Tf�y«�1 are �?r be:cr�me a�s�are of errc�rs iii the data t]lat s��as t7secl, the calc��lations El�at were anadc, r�r tl�c plan pro�'isio�js ?hat Gy�zre ap}�lied, it is ��au�� �•espon:sit}ility tn cGntacE the plar! adininistrator. '7'he plaa� has thc ri�ht tn €•�co�er fa�«in �•GU ainounts tltzt v,�ere paid to yotr ii� ei•ror. � 9;k:k�YV�cx���'rx�#4:�lc4:'r.'r.xi::�x:a;['r.kxk�: "�"�'1.1515 �IIIY `ciHi �'��1ij7`e��'� �-Y.:��Y�kk�:�cx'r.x�:9ck'r.�Y:l-Yr�k:cr';'r.xkic�t �iFt4 Eiei�etct C'al�;ulzitor r,C3224} � 1.0.�7�i3.1 IS6fi {154C�1) !{JX 31� �r"7,'2013 ]0:4.};39 r't�9 �� r1 L1' _ i �.� `•.... V! I vl �'��„l p �� fL f"'i a t�+?~yd py !' :\ �iVlPL�OYEES' �EPA�;�TEQ�J �,4`f PRE�EF�EI�C�S !� 6� 3'_4�. � -Y-5� -��, '�..J.-�? ��.��. ��� �4�FER��l�� #1 Empl�yeGs c�r� r� c,�i���� :� 1u:�7�p s�.rr� ���yri°::==nt f�r- ��acation, flo:�ti�-7`�� ��o:i:aay pay: sivk I�a��e i��uunti�.�e, �on�.Fs :�ay� [if �p�licak�l�;: ��?d �1�2 of au�ru2d sick le�v� �t 'thc tirr�� �i s����rat�cn `�o�� the City. Thcru +.rV�il! t�e nQ ���uc4io� fo� ;�znsio�i � r��i� tr���s lurr;� �um ;��!rrr�°nt n�r wil; tf�is am�unt caunt �� earnirt�s in �he calcul�tion of =1�e ;���si�n. T�e !�st �a�� ot wor��c �,r��ll ha� i:�e �e;minatipn �ate anci �er�sian ��n�fiis w��ill beg�n ii�e �allo��,r�rir��� mas�th. PREFERE�IC� #2 C�TIj��D'�C� C�f1 ���n7 termit7�ifnr}, �ate :�y part or all of the tirne �ue f�r v�c�tinn, floatina h�li�a5� pay; 5ick leave incentiv�; �c�nus d�ys �if a��ifc�ble}, and 112 �f accrt��d siLk lea�e. Employe� rs�ay c�QOSe to run a�t tl�is time i� any ;na�rer. B�lanc� v���ill be paid in a lurr�� s�am an �m; layee's fin�l p�y��eck. Terrr�in�tion ���e ',i'�Jli� `�G-' ��� ilpl�aE G�'�i �i °n �i 1��G' i13ilE. ��i I�IGi i`��s a°flt5 �Vli� �7EC�li ��il� fUf�[7'a�ViCiC� fT3Qflth. _:� [, =w ��;-1�:'�. �4. �.L�,�`�'�_���`�` '� , an empla�ee of f}�? Cify af Clearwater, l�ereby a�ply for pQnsson �enefi�s under �he City's �mplay��es' P�nsi�n Pf�n. k h�reby certify th�t I ful6y undersk�nd tV�e preferer�ce� offered ta me. ! chQose to reiire �sing se�araii�r� E�ay preference � �.-� and lvish my b���efits tr� be calcuRa#ed u�der tl�is �re;er�nce. Pleas� use my le�v� in f�re follQwing manner: Run Out � Li 61`1 p� LI Cil vacation sick floaters h�n�ss hours ',`� � �,�.���ac��i�n �-�`',�-� �ic4� _�� ff�at�rs ,�Li � bonus hpurs i un � rstand that my preference c�n�ot �� cf�ang�d once t}�is f�rm i� sigr�°d and ih�# rray d�cisi�n is i.rt-������ble. � � �MPLDYEE�S 51GNr�,�L1RE `�� f�_ �� ��/� WI! f�ES�E�: ,��i� ,��: 4 .::� �'i+ ��^= ��-+�' =;c��;��� ��c�2 �Urm 1a3�7G-n��p� SQCIa� S�CLlR1T'',' �: r";DD��cS; % �i 7�����;r� ��/� +� �� __� � � .�".�. PHC��JE: %�%-° ����� �.ATE: � � /� File �lam�: Em�fa;+e� 5����r�ti�n Pay Prer l� � � � Y � C �, L �;�i �� ���J :3 1 � }� ���s�aa� �r�rjY���i��v� r����c�� ��c�u�sr �-a��n �a�a-�,�z�,��ous �ur�r �����v�� � �-.� - �__.� r � ��, Q a P N a i � _ __.. �I i �`..; _�r , F I �-, � I i�i rt r�� ry� ��e�eLr a��ply t� r,.c,.=v� b- nufi:�; .�n�ier t`�� I�li'y� rf ��udfwr�c�i'.�f vEf�E'i�� Fi7'Ir]�llyE?S� P?f�SIJ(1 �''3c7!l :l'I r3CCC���3!�CE wh+l`Lrl Cr1L �Qi�C7;w!If'a: C]�t° of E3iri��: [` ''�'��°��° 't��_l""��� Gencvr ;cirtil� on�}: f��l FA�° Jau G�assirica�ian �+�`�`� �F_" ,Y, t�c�.+��i"`r it�'tC�h_'y__�. . L�r. � �t.y. l?:`Y',(C:i_;. l z f"�,. �1VISIdf1: }�} i._�;? }�l_iEr'l ���'�� i:��'1�,�'y \ De��ri�r�ent. ��.+ , �. _ . Dat;, bf �lir� t',�t '`� ' �d� � �a:e cf 5e�ar�t;�n: ._��?'� ��-.�..`.5�'� 4-� i f3�neiits E��c`tive �at�: L.���C�l - � �� __ __- S�ouse s 1Var.�e: 't���f_'��y��� i�-�� . ' �C_'v� ; Spouse's Dat� �� ��i�h: �' l�'. �i ��---�1 �, Spause's Ge;�der ;circle anE} �f�l ! � _ ,N 1�h� t�pe of p���si�r for wk�ic;� I arn apnlying is (c,�eck or,ly �n�}. .� F�eg�lar P�r�sion bas�d cn yea�s cf s�r+r€ce J��-connectec� Disabiiity P�nsion Non-jo�-c�nn2ctec f�isabilicy Persion T'h� Gity of �learv�r�te� Err��l�•yees' Pensi�n Plan �rcvi�es mulii�le ��ptiens to Pl�n P�r=icipants a� �°a the manner aF 'he �er�si�n k�� n?r"i: paymeni. Gptian 1��elaw represer�ts ihE siandard ❑r narr-�al €orm of �-etir��ent �enefit for Par�icip�nts eli�ibl� to r�tir� p,rior to January 1, 2C�13. C]p�;or; 2 o�1o�v r��r�se��ts th� st�ndard ar nor«��l f�nr� of retirem�nt �enefit for F'artic��ar7is �ii�i�le ta r��i[-� after Dec�n��er 31, 2+�12. The nk�er optlo�sai �or�ns �#�3- #7} sha[I he c�rr�pu��� to be ihe Actuaria� tq�.�i�alent o� th� resp�cti�e rcrm�l ben�;it. Qption '� - Jaint and Survi�or d�nnuity [�NL.Y E� el�qible tic� ref€re pric�r t� Ja�uar�+ 1, 20'13 �� annuity p�'t� rn�r7t�ly f�r the lif� of th� Pariici�ant, evith a 1G��J�� sur�i��ar anr�uit��r paid mor�rhly icr � pencd �T sivR �y�ars fcllovuing T�e r�zaii; of t�e Particip��t tc f'r,� beneficiary, provid�d that ����'�v�ing s�ch 3iwe ye�r period the �ur�,�ivor annuity shall �� reduced �a �0`io of tk�e ori�inal survsvur a�nuity �;�ount. [See sectirn 2.3�7 j�y (3j (A}] rhe f'ar'ticipant's siirvivi;�� spGUSe receiv�s the de�ignated a��o;�nt for the rest cf I�fsll�ier I�fe or until heisl�e rer���r�i�s. If ;�o surviv�n�? s�ao��se, deperid�nt chil�ren ur�der t3�e age o� 13 s���ll b� d�.err�eci tr� be t'�e ben�fici�r� �n� receive th� c�esignat�d am�unt }�ntil t?�P as�e of 18. [S�ction ?_.39j ��} (3y an�l Section 2.3�8 �}�} ( a)] iian 2 - Lif� Arsr�ui �hv �a�iicipa��# �ecei��d+�.:s �is.+rier �ensiti� as lor,g �5 hcfshe IivES. L)porl th� d��th af tl�e Paricipant, b�unef�ts Gease. �vctia� 2.41G (�; and S��tian �.42� fb) (�) d. 1.j � �}ptior� 3 - "� (} "�ea� �.��`iairi & Life ,���ri�it_y - �o�`iG�sY �esigsia2e a ��nefrcia�+l) 7he ?arii�i�an� r��:�i����es his.'h�r pens an as I��c as helshe livds_ af the F'art;cipar�t uics be?ore 32(� m�r�thly ���r:�2n�s navE ��en m�d�, th� r�rnaining paymEnts up ic� `n� i2D p�'y:�n�n?s a�e m�de ;o hisl��r �eneiiriary, �r kn� esiate �f hislher beneficiaiy �s nc,t aliv�. ;Secti�an ;�.42� ,;oj [2J a. 2.] Qpt�nn �-�a%4 Joini & 5urv��ar,��nui - 4a�€asi desigr,at� � ber�a�i��ary} The Parki�i}�cnt recEi�.�es h���he: �e�si��n us Icng as re.+'sr° `�ives. Ir th� P�rtici��art �ies fi:st, ts�� her��:f�!:i�ry ��!;211lE� ";�� �Jef:;�:�'l: G; ``l2 ;�!E�"1SI��fi f�� ihG i�'�� ���'f�C bcilFflC;cf}��5 �li?. �i ?I'�e ;!E�IE�I�'I�I�J �IE� TIfSt, tlle ��rCl�il��flt iil�y+ E'?CI �11C�i:�f fJ?f'�.iICi2;,;` C� IY1d'f C�f'Ilfli�l2 iQ CcC:.IV'E 1±�C��'.� ��f hl�,'}�er C�f151�.�� �flrJ` upqr his.%i":�f ;�Eatt-;, C]Efi��T!�S C2�5�. �Seciior 2.424 �;h�} +;�;1 �� 3.] Jp4ion � - ��ia Jasr��t � �arvi�ror A,n��ji - {��.��'t �e����sa�� ;.� �¢�Yii�iaiy) YI`?� �2!�;I.,l�a�l` `?C21'•!v5 f115�i1° ��'I�;Irfl 3S IGfI� �S f'c'Sf'? �!'JES. I` t;1E �� I�S��:'li �I°S ffei, i�i2 �'2iIaTiCI"���,,` ��.:?I'J�� ?5 p�rc�nt of thE per��i ��� fo� tl°�e r�:�t �f °h� be;�efici�r�'s iir"c. li °ri� �v-�?fici�7n,� di2s �irs�, tr� Pa!-ici���ni � n;� f e:�ct af?G�fl�f �+�Il°fl�l�f`j O:a f?lc�;+' COIi�s:lL1E ±C. I"2G2i'�iE �'��'',�o C71 his���er pen5i��'1 aflr U�wil ��:ISi'�-�'f CiP�.fh, �?fl@fiI�S CL-'2v2. `� 7�C`lir n L.11%4 I�J � I` �'� r,. ='. 1 , , . . � ���tio�� 6-`l{lU°i� Ja���i � St�rvivor,+'�i1PliIIT1J - f tT3CS5i ti�sigr��t� a�ee�eii�:iary} i h� F'artsc�i�ank rec�ivzs hi�. ,ir.-r pens���n a5 �c�n� as h�Ish� lives. If tfi� P�rticipant �ir�s firsl, t:�e �rn�`s�iary �e��eiv�s 1i)(, �:k:rcvnt c?; khe ��°r.:sior� ;or th�_ rest �f rhG b�r��e;i�i�r,�'s lif�v. If ti�e l�er�efic.ia"_� u�ies first, trz F'=�rt��.':i�ant m��y ur�:�t 3�Ut��°r b�r�efi�:'I"r�f'�� C]f rna}' CGnt'.r?UL :� ��CPI'V2 1!l;�'?� rJi I"ll��f1?i i7pflSlvil �f1CJ I,J'�i�fl iliS+�h'�i d�:�iTil, �7P3�iE�ltS C?35E. �Seciio� �.--�=� ;�'+ �Zi � 3.] Q tion i— 60 �I3'fl Joir�t & Sur��i�or Ar�nuit -(i�i�ss4 des�c�nate a�eneficiarY') Thu F'a�ticipurt rec�i��r�s his.�'�er �er�si��r �s I�r,�� a� h�lshe f;��res. If �he ���ic:pant �i�s fi-st., th� r�n�fi�iary r��ei��5 6h 2/3 ��ercent �f the pensian ��r �;�e rest c� ih� Len�fi��iary's lii�, lf khe ��enefici�r}� di�s rirsT the Farti�i���t ma,y� elect an�thEr �er�iiciar;� or m�y cor{inu� �n r���ei��.�� 1DO°�o of ris,'her p�n�ian ur�d u���n his,+'r��r de;ath, henefit� ceas�_ `Se�,tion 2.424 f,�l, (2�j �_ 3.] Partial Lum �ur� Pa ment � �ior� �. parti�i lur�np sur� paymer�t equal t�� {:-:ther �en percer�: i,1Q'�s�, iv�.�enry ,�ercer,t [��",�cj, or t's�;rt�� pErUcnt ;3G�°/,} of the act.�arially cJztermined v�lu� af ire r�c'mal retir�ment k�en�ft au� thz men'���r rfi,�y �e elect�G' in cornbinatian �vith �r�y �f the o�tions in ricai�d a�avP. If a m�i�o�r elt�c�:s s+,�ch a�asiia} I��m;� su��7 distribuiio�; t�v°r: tl�e m�nt'�;I�.r reEir�n-ien� b�nEfit ;!�r t�*e c���tia� se€ectc� shall k�E rQ�uccd accordingly thereafter. [5ecti�n 2.424 (b} �2} �. 4.} I n�ve consi��red the t�arious be�efii pay�ment methrds urt��r such Pl�n and f,ave ele�t�r-i ta reu�ive my r�tirem�nt benefits a� ind3cated beiow. (Note: L�ption se'ec�ia~� tQ t�e in�ic�ted b�th by l�lumber ai Yd C�escrfption.) � f:i1�2� 5���'� ��3�u� '°.�'T1C° !?? a� €ircfi ngC75!!�?? d�CC}( ic ���aiV2�, !�"!�' Cf�GISI�CI O�? $�"i15 Clt]flOfi IS Iii2Vf]C��1�E.'. If takin9 {�Ption � sign, be9ow: __ ___ _. _ _ __._ � C�ption �: 1 C�escr4ptic�n: �c�irt and SurvivorAnnuih� � I Em�lcyee's Ssqnatiure: _ — .. Dat�: _ ; � Q?pend�nt ch�i�dren und�� the age �;f 18 and r�:�iding in ���y household are: Child's Narre Gend�r C�aie r�r 8i��1� 1f �a�ing Q tip on 2 sigr� �elo�r; _ v � �ptEOn �: 2,_ f�escri�eion: Lif° A:�nuity _.. I�� � r p �r•Ir�y�e's Signatufe �f{�f°'� � ��_ �. ,f!,"r� � J'..s-�-•t.y:� � - taking {7��io� 3, fill in €�er�eficiary ii1TOCiY3��IDP1 �n� si Q'�]tlGil `?t`_ � . �1FSCt`I(�[Ivi(: _ 'i_�� Y, �� f'��y d��ignat�d h�n�fici�,ry is: hJ�me L�ate �r Birth: t�ate: grc �selauv: r Cerf�in and �...ife Annu cocial S�curi!�,+ iVumbe�= — ia.-�der �C;rcle C)ne} M F � ,�dd�ec5 . � Pi-,cr�� Nu:�,�?��r; _ Em,�{��,r�� � :5i�naiLlf E: _._ _ ..._ Da;E- ii � �r -:io - '� - n; a ... —+.. . _=` _ ---i S�a . ;-i �s 1!f"1'� �� �� �errr� Fa,�7+�'1nJ: t�3TiVE_]C1 'JFCJi6Vi3 ti�. :J, �i],GI r iii iis :.�fJiivBi i'aiiiii.i.. i � v ��UE iiy ^viw as:G :�..,;i :c.� f 9:3.C; "tic'J - - �1• �--- j �`):,tinn t. -- D �:;ri�tion �-�, ..�ir7t ur�i �����? ;i �-.� ��uir4� -- P�+1,.� d�e�ic�n�t��i t�ene�iciary is: Nam,e ac�e or Bsrt'n: H�C�f2�S � FI-�on� Nurr���P=-: E:n�loy2e'� Sig�a��r�: 5o�:al 5� �.:ur�t,� €�umL�er: ;;�r�der jCircl� L`n�j N� F C�at�: if taki�g a PartiaE L� Sum Payrnent, fill iri Perc�r�tage_ar�d sign t�elow: _ Op'ic�r� #: _ NA Description _ Partizl Lumr Sum P�ysnent ___ {�lect t�� t3ke a par�ial ;�mp susn p�yrnei�t in �h� follo�^rin� �rr�aunt jc"�?ck cnly one}: 1G°i� af the actuaria�ly cetermined �alu� of th� narrnal r�tirRmen� benefit 2C`�o of the actuarially detcrmined value c�f the norrnal re�ir�m�nt i�en�fit � 3C��/o of the aet��ria63y deterr�ined valuP o� ;��P �orrria'i r�tirement ber-��fit � 1 understand r�y m�nthly reti�Ement bunefit for �he o�tion sel�cted aa�v� s:�all �e r�duced �ccareiingly. Employ�e's Signature� lf �aminc� a beneficiary QP�LY, fi11 �n beneficia Nly vesign�ted �cn�fsciary is: BEnefir:ary �fame: . __ Ben°fici�r�1 i��te os` Birfh: B�neficiar�+ Rddress: ' E3eneficia�y Fho�e Numl�er: _ _ _ �rnp;oye.e � S�graature: _ — _� � L ate: infn�znation ar�d sign b�lov�r: __.. B�;-Eeiiciary 5aciaf 5ecuriky � Senef;ciary Gend�r {Gircl� Onej M F L�te: �,�" ;. .-� �:��i- �LOP1C�:7 � :�r .��.C�'��Clflc.� I���:��:��,�e^' ',�.�G� zC.�r�r.,,,,:ir�geJ 'oeio�e me thl� COUti Tv u�F ;:•���..��.� ���:1 �f i"u\��� _ �.,� �C� �If�ELL.'1S ,r � i�..�l�'•::r��� ,,��� ,: ;� b}f �.�.=` � u ��... '`�-,_ +`^ tr�'�c� is persanally known to me �r v��ho h�s prc��i��d - �s identific�iicr and �s�hc� did!�id r��t ��kE ar� �atl',. $��Notary Public stat� of F�onet� .�.. -�_ .- - , ��na �'frieste ���,'�'�,� �..� :� ti� s. ���. q My Commiss'ron EE 2U4342 f igna:uret ���� £xpires 4SP�3120�� ; _ . �" � :___a 31 ��.T. . •$'�� - � �_�V.. 11 ��"i"�-_.'- r. �v�y� Ccrrrnissior� vA�ir��: t��-a= � i � �� '"�1{_::1��� �iotary Public Na�r�e �f �J�ta ;� Prir�i�� �E�y� �;4?13 �cri�n ��'90fJ-�OOJ � ile ���m� ��nsic� Eniitl�m�r�t ��ii��� arm �I I 7� i�` l_.LC:�1f�V�L1-1 l L,ti �,�}NU�',L i�;E�TIF!•�ATIC�N Qf PE�l�>l�N EP�iTI"T 4.�hti�lEN I Intorm�iio;� ancl lnstru�;'i�n� T�� en�ure ihat pcnsior, hrnr�irs �re �Se;�g r�;��erVy F��icJ a4�J recei�rer� #�y p�:'�sior3ers in �,c��urda�=cv w��ith .ri:: F'��si�n Flan, ��:� ar�nual r��ri�.+,�.� is p.':if��rme�. This r�,�i��.�,� is cancl�icted �7n b�flc3li ��i ?h� Pen�:cT; ra�lv�sorY Ca��mi�tec� �s�ci P���ssar� I r!:s`�es. 1 f7i� �r:�:i�:al C��tifca�io;� nf ���sic�i� Entitl�rt�en: is a�signGr� tu �r���iide the basic ir,�c�;�r�aiia� neec�e��� �or th-ie �n��u�l rev;E��v. PI�'�3S° i71G'K� LV�f'�1 E`ivf't i�7 ��f1l;i�er.E all s�ciie�ns vi �1 �E' fDfR1 I;? �S r�i7f3`1�J�Ct� �3 �7�._�fl��; �S �]C�SSIG�E. 1+`VflP.1�1 '}'OLJ CLn"1��Bi� t�� fOi�?�. It R"iUS: ��C SICIf'I��"� c3pG� i1Gtc"3�IZEd. T1�er� rvt�irr, the roY�r to: Human P.esaurc�s �ep���me�rt Ci{v c�T C`sean�Y�at�r P� �. BDx 4 � r-� Cl�����rat�r, F1_ 337�8 ��_:�_rtant Note: Y�u rr7.�st r�turn th� ��m��'eted �orr� pri��r tu r�ceivi��� yoiir first �znsio�; ch�ck rr yc�ur �ensian �er7Gfits }Nill o� �vitl�hal� p°ndin� r��e�pt af ±"e ��Qper��,+ cc�mp��`e� ;o-rr... �� �ct I��v� any �t���tion bk�n,K. I: the q�sa,ki�n �+�es not ��p'y to ;��u, write "daes �nt ap�ly." Section �. Ernployee-'�ens�vner Inf�rma�ior� 9f you �re tf�e pension�r {setire� emplo�ee), y�u ��nj.�st t^omplete th:s sPCtior�. If yro��r ���sion Es a�isat�ifity p�nsian, r�ii r-n,��± �I.cp �^r�mr:!ctc Cat`F•r'r I!I II �7G�I ;r[? t�cn e�i:�!,r,.�E,�xririnwa�r ��frig r � r+ar•bnri�t�= 4i??`»i��r�r f� f rrnar j.... , 77 l�. r'L. u , rJ. �.`...._. en�pl�ye�, �,���iie �n "c��.�s s�ot a�ph,r" far S�ction I and pr�c�e�i t� �ec`ien Il h�lo�,�r. n. Ernplcye�-P�nsic��:Pr N����� of E�nplay�e-P�nsf�npr: 1`:�C �� t��.����.. 1iz' tC;������.'�.v,`=: Ad�ress: �� � I��� t�•�+�k'�� i [ . 'tti C _lt_ ___. �. t ; `� � ." �� ��-��.c� � i'�., :�'._ `�� � c� : :� .�_ ��� �- � Y �-= - _ . � r Pn�n� I�un�s�er: .Area Co�� i_':�-1 �o `r��-�[�C- _ �_ ��Jr� `� E-mail Addr�ss: _ .. _ 5c�c€ai 5�curity iVur�ber: . C7�te Q� Birth: ��-�'�+: �% l�+ ��-��`J Maritaf St�tu�: Singl� Y Ivlarrsed " divarce� '�l�lidQ�v(erJ __ B �pousA of Em�l�ye�-Pensic�ner hlame �f 5pouse: ��-,�:�e�1,'�� `4ti7'LG�:�'����_;.y,� �, w _ � � � _ r"�dd�ss: � �e L� ' '��-`O�i.. t �.- t ���'� �. ' � �_ i_z � �, ''� � �: i�..�'e;..�--`� i� �4•-'C` � i r= � . k �;_ .y' e _��%.o �°j ���';,j..� �n�r� Nui�ber: Ar�a Co��i� N�. J - S�cidl �acuriiy €Vur7��°r: . _ Gat� of Bi�h: "_-:'`� �.��'`���, �i i:�f ��i�� C. G��end�nt Chil�rYn of Ei � ��lo}�ee-Perisic�n�r F�ill r�arres a�d dat�s of birth �f dl; your na:u�al or Eegaliy �doptpd childrer:• und�r the �3e r�f ;�,.�f�=ven �'1�1 fi�.�:r�g i;; y�ur h�usPhold anQ d�pen�e;-�t u�i�n yo�� �or t?�,eir sup��rt: �gam� Da�e of Birth: Num� ��.�te cf �ir�;�: iJamv: Date �i Bir€h: �ivi�:. -s;:�_, �� - . �� _ ., t�� .A� :act.Liiii� �i. .b�..,...�, ��:�. ... �u'y, . .�c�.�.'�s� , � . .,..� i�.. .., , -iv.:rv , :�� i r 1 �1 �i 'yr�,J�i Y;r.`.'. Lf�:�'++"+`ICjL].�v"a�Cri -ir'.fl�l r;y�`} �^�I �."�r�.?��:Cf'cl�t SL:f'vl'.'Oi nf ar °iil��l:j°F. ��f1�IG�i'�I ��OU fT�ILJSt C'Uiii,rJ:l2'L°. ih�s ��ction. ��fil G(u4'Jli"SQ SLIf'.�iv�rsnir perisic�n �en�iits a� Ih° '•f:l:j�,'.�Vf c;fl, E;E(1�fCldi,y', C?i LdE';�Efl�r`'.-fli S�_1fV1�lC� C�t: Nam.: �T E�r;pl�y�e-Pei�s�uner: - „---_ _ BG:�i� o� �elati�r,ship :o EiT,�ID��2-P21�SIOner (Check cnF khrt applies} l+"�fid��GV��,j ,. B2f1E lcsa;y _ Dpd C��iid �pd M�tre�_,: �,�� r�ther �urvi���j's Guri2fli Iili��r"i1cs�I0f1 ;irfor�azion �b�u; �y��;. f�k�me: _ _ . � Addr�ss Pi�on� Numb�r: Area Gade _ N�. _�-r�asl .�.�dress: _ _.__ Soci�l Se�t�rity Numb�r: _-- - -- �. C�aip �f E?ir*,h: _._ Have yflu marrie� sinc� y�u Y��qan receivir�g su!vG��orsh;p pension bPne�ts? Yes N� _,. �f yes, �ive c��ie cf ma�riage: __ .. �ect'son 111. C�srreni Emplo�yrner�t and C�isabili�y Infarmatinn IT y�u �re r�c�ivir�g a disabiiit}r ��nsion, you r;-�ust c�m��ei� this secticn. �,nswer �:ver�,� quesiion. If a questsan c�oes not a�ply, �nrrite "dces no' apply" as yo�ir answer. ,�, Curu��nt E�nployment (k�cludes S�If-�rr��lo,rmentl A�e y�u prese�t;;i �rnpl�y�d? �Check ur��;i Yes hl� If }+e5, prdvide the fokla�4w�ing inf�rmati��: Narne o; E9nploy�r. Em�Ve�yer's �,ddre5s: � l�!�p�oy�r's + �,�ne: Are� C�de 1Vur;�her � CJ�scri tia� � of � au e� ia !��enT list s�CITIC i' �al C1Ut125 fh3t o�� ��ifarrn = A ! P Y � p ���� Y } � W �, Disat�ility Siatu�: �Ily di�ab�lity p��sicn �,��t�as: ,J��-c�r.:i�ectu� ____ M1�an-j�� conn�ci�� Job CiasvITIC3iIJl�: EfiFGiIVE �e:irem�!�t �aie: V1J��t 4Vas in� r��iure aT k��� dis�bi[ity tha't ����Yd yo�.�r reti� Ement? f Descrihe) I�o�s rhe disabsliiy stsll exisr? Y�s �o : �nea ihc elis�k�iliiy sfili ��Fr���e���- x��o�,� �r�rr� per����r7�sin� �f�� c��_r�s�� ui E;�e ao� LI�SS1fc�:tion y�� 4 I-�el� ai �i�e iim� c�� ��r��_�r r�tiruaner7f .��i C]':5==1�Gi�4i'J uBf:�ICU[�Ir ;�i'�, �," . .�...�.;_�., _.::�--e,.r.�:. _. --- - -- — ��-- 5actian IV. Designati�r� of Persc�nal R�presentatiWe Ti�� �ity n�r�R io k�e n��kifed in tne 2u�ent �� y�r�;r deat��. 'You r,�e.:j to r;c����,a^ui� a ���rrii�y nr ��ersc?nal r��;esenta;;�.+e tc ��ar�;:le if�is responsibility. (LiSi tl,:� n�n,�� �i tt�� p�rsan ��o�_i ex;�ici ta d�� tho�. T`�:s is ��i a�indir�g J�;ci�ior� ;�n;i �:;�y nt;~�ur ��erscral rP�r�sent�:tivG n��y �tierr� to ihi�,� �esp�nsi:�ility.} 1 h� farnily or pers�s�ai r�p:-esPn'ative ��ho �viil �d�:�i.�� tt7e i;;ty� �f Cl�an.^r�ai�r, in r�riti���, upar sny death i=: hJame: /� G'�.�.�_._ /��% '� � � -%' _ .�;�iu�ress � � ���.a'.� � � �'� .�-.� _ �Ci�:����'� ' �'�� '�_ � � ��f,.�'_ .� Pnone Numt�Er Ar�;� C€�de i,�'7 --- �1urn�e;__ _P ��. � � �°� "7'- -_�� - --�—� CEF�Ti�'ICA7IC�N 1 he«t��� c�rtify that �II the �recedinq i;�far���tinn in e•�+er;� sectiors is true as�d curre.�t, ard 1 arkr���.vle�g�: that ar7y f�IsiFicatior of the pr�ceding infonr��tion cQUld bE conss�er�c� �r�udi�ler�t and cc���ld result in my �ensiar; ben��ts �eing withhPlr�. ,'�- �� �. _ x . ...�"�� Sic nature of Perscn Re�esving Pensic�rs P�w�r af Attc�rr�ey (ff Power of Aktorney is n�ce�sa�y; ait�ch � c�py.} STATE �� F�DRIaA i hv fcrpgr�i�g ir�str:�ment was acknowl�dg�ti ��forG me this��[)'��c:����C� 1�"1C���'c'ti=�� CC]UN i Y�F PINELLAS �� �.�:,, �-1�� �Z�.� t`°�0.-�41rr�:ti��';`.� ���ha is �2rsana(ly know�� tQ me or who h�s p�a�uc�d i-.L- �7�--- ��_�:: ..� �' �,'"�' _. ` {=�� -. ?��_I- C �� as ide�#ifsc�tio; � arsd u�rl��o didl�€d not t�ke an oati�. ;�.-� s�_ �'�.._ =� • �`s�, C�.�_C - hlota�y� P��blic ;5i�nat�r�} m ;,...'� �t ��.�._ :Y'. __i �� i � �-�'��-�- (T�ame o� f�otaiy Pric�tedj � 1 i.Jir�,.��,:.`�S��IJI� IVf;'. � _�C.-•t-i_�'lL � m __ �� _ � 1`""^� �a�� hloiary Public S#a4e of Fl�ri�ia � , Gina f Triesie .� � ��,� �uly Com€nission Ee ?q4342 �' essri Expire506l03l2036 ,y- '�"' �r�+s �, rav;sad 1JV� r.�rYi �' J�.^J �1_'r�.+ !=il= hcmE�. F.cnual �t�Y, ns F�nsir.� En'i11� �t�err�her �l�ta N�rne laati nf Bii�.h A�e at Retirernent Bea�eficia�•� Da�a ?� ara�e. �3T� C7��li[f7 A�e at Rctia'�it3e��t Retirert��nt �ata Hire Datc Tei°minati�n Date EfFecti�:•c T7at� f�:"�C' �, 011 l�rl �7L1[I [] Si 5 Int�rest �ity� c�f ���ar�r�T�t�r ��play�e�p I��tir°e�rae��� ��'stem �3ene�t ��timate lti ORNI;9 1•I:41'TH�.'1'+'S 061U1i 19��3 (i5 i'ears 1 lion#h �ro��r�:v naa��r���t�.w� [�fil(i"�,� 1948 65 Y'ears [3 1�'Ier�ths 2�. �]ays S�e•iai 5ecuri�,• Nn Social Seczirit3• No XX Y-\X-4812 Relatinnship : Spause ��f' childreil undc�� 1 ts' : 0 U9129i1992 Caic�ilatinil Tv��e : '�;s4intate [16I29f2[�13 ��' �� �°����g� Benefit Cirflup : Non-Naxardnu5 - Gr�ndfathered (17!{1112013 Retir�i�zent 7`�p� ,:: : Normal Retircnierit :� 3G,4G9.2� C)p�tioe�.,�Iec�cj -. : � �.d1fi � v.�u _�, �r Fornn�l�� for 13enefii r1 : 2,75°/u � 2fl.7722 years � 53b,�G9.Z'� " :;°, . . :� � -;, Farm �if T'a�y�mcnt ;, �,,� � Factor No��nal N«rm � 1.00C]4t] 5inglc E.ife Anr3uit�,� �, �.�� g� �' 1.12�25 1 U`Y`�ar C�:.��tain aild .Life :�zmuity� �� �, ��- 3.072 i& �0°��, 7t�int and 5�in�iti�c}r ���� ].03�}�i5 � � �� l ,(]UI5�6 ?`�`>.�� Joint atld S�en�i�•ar .- � .� lC}Cl°� ]oi�7t ancl 5urviva�• xa:�'� '-'�- (1.9bbf39 rp'�. , �r rh � � '!'7� � iull � `,�'�.I}Q �[� %) Servic;e : 213 �'c�rs 5 fvinnihs �S Days Monthly Bene�it Patential To 1Vlember Tc� BeneCciary $1,73fi.a5 Nlrh �1,3�l.?b N.�A $ [ ,86 E .3 � N;'A $ i ,R[14.8g. S9{?2.�5 $ I ,739.�� 51,3tY4. �8 �1,�?&.5 i �1,678.57 '��T1lC iJ�Ii�CS t�k��?!:i`;� k,:l]"?: fC?7' l��i.lti[f,9C1`.'�.' �'�ll]ts4�tiL.-: U[ij'� k:ll?C.� L�,f7���4ti r0177P1.1111[l.c3tci: l�?[ .�_i ,i-iS�:: wl7ty�.li.C'1 f..:t ..��',�: l[:�t:l :t5 :lt;Cll l�c>Lli�=�- This Ci31CLE�clE][71"S ES SL1L��CCi XfJ C�iTZCIIOII. If }'ULl ill� 07 E}�CC13T;� c`L�l'8C� Of �i71?TS ]Ii t�1E C�1i8 t713Y lVd� U��C�, C�7c calculati��ns that were n�aae, or [hG pla�� ni�r�� isat�4�s tl�at ���ere ap��licd, ic is yr�in: res����nsihi�ity io cnniact thz }}lan �rdi73ini5trato�-. t'h� plan has tP�e right t� recct��zr ��oi�� y��u arna.-�t�nts that z��ere �s31� TO �'L�t1 iIl errnr. 'r, 'r, :': �: k :k� k -Y, .-'; x :F :F :c �c �"� �: :k •� � 7's -fc ;': r. �c �: i: x A '�' �� g � A � � � d �'` i � �'� ��. 1� `c� ! � ;� � 'r, �: �: 7"r ir �:'� 3; 'r, sY �r 4; :k A �: �: il• r �f: :'r -k. J„- k •k �c �c 7F� GR5 13�>>eri� C"al�;ulalor (C' i'?tlj - 1.O,q7'+3.194ti1i ( I�aSll i Il]\ ;0? �? 34i2U13 �: ]�:?ii I'l7 � �� v � f a L,i i � i � pH f iYinv�1-'1 I�. I 1 �iV1PLDY�ES' SEPARATI(7�] P,qY PR��=ERENCES �� -�- ��".,� ��.� �i�� .�� .�_ � � ��� PF2�FER'�NC� #1 ��7�plo�.��es ct�rr rac�ive � Pui�n�? sun� p�y�-����t ior ����atian, flU;�iing t��rlic-.i��,� �a�y, sick ��c3'+It; if�G��fltl'VP., f]Oi�kUS Cf"c]}�S �li �3��7��]Ge��7�e�, �f�L� �r2 G'i c'�Cl::l.lE.'Cj SIC:}C �Er�VC c3t i�s�.' t4f31t' c�f sEEaar�tic�n froR; ti�� City. Therr will bu nt� ��d�rcti�n sar �en�ir�r7 frc�n� tnis ILIf-C-1� 5�lfil ��';�f�Eflt f�Of ',NI�� ti115 �illp�!il� CnUf�t �S c�c`�IC1lf1C7S Ifl tll� C�ICLIIr��f�fl f]f ii�t �en�iun T�e la�q day af vv��rk wilP b� �1�� terrr�inaiion d�t� a��� ��r�sia;� �er��fit� ��r�ll t�E�in ti,� ToJfovring month. �REFEI��NCE #Z L��1E�Ic�y;:2 c�n ���tcF�d term�r��ti�,;� �fwte h�y ��trt ar all of th� tin�� r,�"ue €c�r v�cation. flc�atin� h,�alicay ��y, sick ��a�ti�� in��ntiW�, k���r�«s r�ays [if applic�l?le}, �t��J �if;' of aceruecl sich Ieav�. ErnF�layee rr��y chc��sP t� run o�rt thi� t�r��; i�� ar�y E��ann�r. Bal�nce 4"JII� �iP ��ICi I�i a lLlil�i� �Ufll Dfl �f'E"l�)IUyee's Fia�al �ayC�i�Ck. T�f f111f7��lOf-1 ��#e �viEl u� i��v �ir�al d�;� o� ex�en�ee; tirr��. �e��icr-� ��ne�rfs ��vill hecain �he fcllo��vit�c� rrionth. �..._� � __� �_ , _.-_ I `�'+' �; '!` ,-':.•�. �: _._.___.�_, an emp€oy�e a� the Ciiy af Gl��rwater, f�ere��� app�y for per�sion ber��fits unc�er t�e City'� �mploy�es' P�nsion Pla;�. 1��:rek�y ce�Efy tr�at 1 f.�tiy ��nf�ers4anc il��� pF-Pferences affpr�d to me. 1 choflse to r�tire using s�parati�r� ��y F�iefer�nce #__� � a'n�ci�4visFi n-�;� renefits to Lfz ct3lcul�ted un�ier thi� ;�rei�re�,c�. Plcas� use «.yE I�av� xn the f�llpwir�g manner: Run Jut Lump Sum __ vacation -- � --�v�cati�n sick float�rs k7d f 1 t.E 5�"1 C7 L.! I"S ``-.r°���.l�'�' �,��k _-- :�� flo�ters 1 � �.��'�, _ �Ql"1LlS IlCSLJfS I tineiPrstancl that rr�y pr�f�rene� car�nat t�� �har�g�d anc� this fr�rm is �ic�rti�� and that my dec�siar� is � f �� rev���abfe. � , � ,� / ' / ; _... � EPJIPL�CJYFE'S SIG�J�,TI�ftE: _" �.�-�: �f . , r� 1�;'. !..:�'.� TG'L ,r� li � i. � . ..���._ Wi��lE55��: �.L., i 1�.� _� _ \. yiS �'�i SC�C�f�L SECURITI' #: �UDF�ESS: � `f _�,� !. � �' Jt �` ; �, `. � , _,_. •- ,- r P �-'"(%�L#.�� C % �� � _ � f ".�'r°���r�' ��a��: .%,-�i'�:���'� �� � a�,T�: ��-.���-,i � J � - �y�' � 2� 4 f Revis�r� 1?G2 F��rm #3a40-�a0� =i#e Name: Em�l�yee S�paratian ��ay Pr�,f L" E 1 Y C� F�: L�,"1 i=i V'JA l� fi P�P�51J�J �N7`17L�M�,J� C�Pi-IC?,J R�QUEST F�RiVf hiON-HAZAR�7QUS 1�i�TY EMPLOY�E _ _ _.. � _ _ . _. - — -- — _—.�,_. _.... _ f �. _ � � � '�.� _ �a�4:r} � C� _ . _....- -- — — �s7 he�Pby a���l;� rr� re����� �en2fits � �nder tf,�R � City o� �IcanvatE:r G�.ri�r�l Empl�y�e� F��r�sion �?12n in � uccra:��re �,��itfi '.he f��flo ��i;��; C7�at� �i 13�rt1� '' :?"�::' C:�r.de,� it;irCl� �ne', �.+t .`F, T- • — , _ Jr�t� Classif�Cakiai� .�'r. �r,��� 4z_��— - _ [3�,;��r:rr7e,�t ' : � ; , � _._ Uivisian . . .� _ _ - ---__ _... --_-- — Dat� flf �-i�r^ _�Jr ,� � _ �at� c�4 Separatron ,` :�,::' x I ,r�: Bene`its Eff�ctr�e Dat�'.� _�i ! ' _ — i�r • --._ _; � �pc�se's N�n�e F, � s� � -1t�. 5��.. ic c. � ---------- S�c:as�'s f�ate of Birt��: f e'::�%r �"i.�1_ _ Sp�L1SE's GFnder (circi� �ne}: rt�Jl, � Th� ty�e of pzr�s�on tor ��;�r7icfl E cSf'"rl 2��7lyir�g as {eheck only one}: _y� ..._. Regular Pensicn k��s�c� ors y�ears �f s��Wi ;e ___ Jok�-c�nne�;ted C]isaLifitf �ension —_�.� _ �1�n-jo�-r�r�ri�rted C�is��il€ty P�nsion T�e City �f Clear�vat�r Em�ioyees' Pens;c�n Pl�n �ro��i�es multipfe epticns io P?ar F'�rticiaants �as t� th� m�«r.er c�` khe p�nsion E3�nefit p�yme��t. �ption 1 belc�w represents the sfarrci�rci c�r n�rm�l f�r�ry of re�irement ��er�erik fc�r �'art�cip�r�ts eliqtlbl� to r?sire prior t� Jun�iary� 1, 2G1:s. CJ�tinn 2 k��fQUV represents th� standara or e�c�rrnal f�f��� c�f retirement r�enefit rar Pa�tic:i��anTs eligibl� to retir� a�er Dec�:r�ber 3 �, :�.Ci1? The ather c�ptionaP fr�rn�s {�#:3- �7) sh�ll t�=: e,omp�3�e� ?a k�e th� A,r`tEi�rial �qu;v�lent c�' the r�sp��c?iv� n�rrz��l �en�fi�. Option `3 -.�aint and Survi�or Anrsuity {pI�LY if eligibie to retire rior t� Ja�ruary `l, 2Q13) �,n annu€ty ���i�a �iior�thly fur fhc� I:fc nf kh� Particip�nt, �.+itn a 1Q�'/� sur�rivor a����uity ��aid ir�vnthly �c.= a pFrioci of ti���k� y��rs f�l§c�wir�� the �!e��kh �1 the f'�3rtici�anF to the k�e�eai�s�ry, ,�rovic!2c� tn �t follr�vJing sucr�� five year ��ric��� i��r s�irGiv�r r�fltlL!It`J S!ls`��i I7C �CC�llG�r`J f0 JL;FaOi, Qf t;l2 �f-IC�I`1�3� SLJlVIVQr �SflflUlt!r' �f"T3fl�lf3�. �`�'8� S�CCiUfI 2.397 [�y �3} �A;] 1 h� P�rtic4pant's su�riving s;�r�usL r�c.�ivNs th2 desi�r,�ate�J arr��unt far thE �es� �f r,���r,�r r�e or �,nt�� r�,��sr,e r�r„�3rri�s IT rio survi�ing spc�use; Jeper��;�F7t chi�crGn ;.nd�r thc �g� c�f 1� shdll ':�e de�r�er.� to �� tri� berl�ficiary �r�ri rec��vE :he designaipd am�unt �.�i;til t�i�: ��ae c# 1� [5vctio� 2.391 (�'� �3j and S��ti�n �.�9� �h�1 f1 ]l D�tior7 2 — Life At�nuity �e +.'- �; ;i:;i��3r�i r�ceives ���1'�er f�e ���ic�i� as lang �s f��r'she I�ves. U,��ri ti7c: de��l; af t�e F'articip�nt, he��rfi= � c�asc [�ec�i�.�n 2.41� (cl an�? S�ctinE� 2 424 jbj f,2;� ��. 1.] � �'ptior� 3� 10 i'ear G��ais� & Lifi'e Ann�iity -�rnus�t desi�nate a b�nef�ciary} The Partic�panti r�r�eiv�s �is�lie:r c�r.��?sion �s Ic�ng as helsl�e Isve;, If the Parrir.i��ani di�s be€_ore 12L� rn�n�hiy pa;��n�ni� h�+.c bae,� rr,�d�, ?h� rer���7i��i:��� c�aym�n=s uF� ta k€�� 1'zG p��vir�e;�ks are r7:�ad� to hislher i�ene`ici�ry, o� ;he e.st�t� if ��,�!h'�2r'w�n�iiCia:'y is n�.:t ali��.,: _,�7� ci ,��7 ???4 i a; 12;1 a 2 1 Jpiion � - 56% ,loint & �tirvi�or �nntii� - {must desigrrate a be€��ficiary) Ti�e P���iciparit recei�r�s hisih�r per�sicn as !c��g as h-��a's!,.�� liv�s �f tf-i� f���€�c;�ant diES firsi, thu h�n�fi�.:�ary re��i�r�� 5C] �ercen` of t�� F��",si�r� f�Y Th� r�st �af thc r,�;r��ficia�y'� life. I� ir�� t��r2fici:�r�Y �liES fir'St, thE P�rei:;i�,ian' �n��y r�e��.t an�`h�r benLfiCi�r�,� �r may c7ntmuc ko r�ctiv� 1�+d°i�, of his+'I�er p2nsi;�r. �i��� 'Jl7Gfl hislner �e�tn, bQn�fit� �c�sc jSectian 2.�'2�} {k; i ?;2 ) a `i.] Di7tl�f� �J - �T�J°i„ .�OIfI�L e�c �Lii vS-v�f dAil�#Llt�jl - {TliiIS� CaiSi�€1�It''. � �}L�il�'�;C3�Y]I} l.he P�.;�i��:���ar�t r�r�i�v�r_�s i�:s,'he� renci�r? �s I�r�g cs i,ti'sh� iives I' tl�� ��aitiCi�ani �ips Tirst, ihe r��n�;ir:ia�y+ r�cF�,iv�s ��5 �crcen? Uf iilr �znsicn for trF re,t of the b�r�efici��ry' �!ir'�. lf ih�,} r�neri�:i�n,� �i�s first, the P�rtic:pan� rn��y elect ;�fl+�iflE.-'f t}t�'iIEfYClr711�' QI" fr1�V !=CflCl�!UE �0 i2C?I`J� 1,r1�,1"in Qf rl!:S���IG( �}t''.'�SIC�fI dfl�7 Li�?C:Ci f1i5�+f3t`'f r��'i3tl`l, I7.�IlE'fltS '�r�S2. [:,��cti�n ?.4?4 {bi i;i'; �. :$.] Qptio�� �-�0C1"/� JOtlP]� cYc SL3rViVOi Af7f7iIlI�1 -�V711iS2 LI�Siljfl3te c� �7�fiL-'1`IClc�f�j�} I f�C' �'�J111:�i4�;if'�f fk?C:E??vE;S �lf.�„�l..f � Cf1Sil�li �„i �CI1C! a:� �1C���Jli� �I'V�.S. �i ���E F�c]f-[!C:IIJiJf [ �Ilr°�: ilf. , t'lt. U�_flf��ll.tisitr' C',i;f�l'.r�.ti 1C]C� pe�,.�nk c7� thc� �tE�si�r, �nr tfit� rest oi= the Lr�ric�f�ci�ry'� f.t�. I?'the Lf=n�ficiaiy tli�s firsi, zh� F=s3f?I::I�7c�f1[ fT1J�' P_i�CT ciilUlflE'I E�'�flE:llC:lc:tly Gf I7S�3'y' Cf7lltlllL,c r0 �cG[:IL'� �[i��`iu Cif h7is,��lc'I F7Eli51;71� �f1L �.II�^vfl i11��I1G'f' G��lifl, �7�flE'fl[� ;:E't;15E' rC�''cai;LlCfl �'.�7!�r �:)1 �,! } ;] ��,� � C}�t�c�n 7- 66 `I3`i� Jaint & S��r��ivc�r A�7nuity -{rnust rfesir�r�ate a berieficiary} Tf1:.' F'�7.':I:� i li I?C'EI�ICS I. 'fi:=' �]vl"lal��fl 'c�S �G(l� c35 Flr'SfIP. �I`Jf�. �f ��"iE f�cif�!CI�1�f1L ��1:=.'S iIfSS, tflE-' �7F'�7i�fl','�c3i� ft'i��;l�.'•'S :�5 ;; percerik �.;i :�iL p�nsier7 f"+ tf�G rest o� �1�2 b�r��fici��y's lif4 If ih� ����efir,iGr;� �iies first, the P:��i;.i��,_ar;t r7��.�y �lect anr�thrr bene:ir��ary Ur rr7�3y cc;ntinu� i�� rec�tv� 1�0`�0 0� i�i:�lh�± ;��nsion �3n�' upon r�islher de�;�-�, k:t.ne,�fits .,e:��e �u�LII�}9 i �.'����F {L%,� ([ 1 c:j .�i i Par�sal Lt�mp 5��rn P�yrnent C��tion A p�riir�l �ur��� s:�rr� ,��syn,er7i e�...ial to eiiher t�n �?�;rcent i i�"'��j, t�r�+en+y pei°uent i;��';��,;F, c; tf��irty ��rt::.ri �3Q`;'�J r7; che �ctu�ri�lly� dei�r�r�ins;d v��l�_:e of kl�e r�orrr�al r�tiremer;? b�n�fi! f�ue :I��e n�ean��i rn:�y b� elec#ed ir� c��r�lr�+n�ti�r� 4vi.h �n�,t �af the ��tioris indic�'tec.i uL»v�. If a rrtcm�ser eletts s:.icf� a partial IuGr��� surr�� c7'ssErih�_iti�n, ti�En �he r7�c�i�thiy r�tFre�rn�nt b�:i�e`it irr fh� ❑; tiaii sel�: cied s}ial! k��. r�r�ucv�ci �cccrdin�ly theF�a�t�r. [5�.�;tEOi-� :'.424 {�;'1 4�;� �. `�.] I have �r�nsir�e:�d the varioi.is l�en�fif �aym�ni methnds under s�.ic�� f�l�n �ncs hau� �:IectG�i io reeeive my retirE:rnen� h�nefits �s :ncJic,:�tc.c! b�:�l•��v. ��Note: Jpiior� s�lecEi�r� to !�e i��dic�ted k�oth t�y �JLim��r and C7escri�t7an.j ! i.rnd�rstand that once rr�� first p�tts�o!� c§�eck is rec��veci, rny decisiQn Qn fi�is c��tion ss irre�ocable. If takin� C)ption_ 1 s�i�n belvw: _.__. __. .__ � ... _ --- ----- � C}�tic�� #: .._1.__ �esGri�tion. _ J�int an�,�u�W�vc�r F,nnuity ; ' Ernployee's Sig�atu,e ------- - -- �--- C�a�P: I---- - - � C}�per:cic:nt c�ild��,� L1Cl�iE'f il�e a�e �a� �� �nd resi�;�lfl(� Ifl r:"lY' ho«sehc�d �r�: C1�ild's Name Gendcr Date c�f E31rti7 if takin CJ tiQn � si i� beiaw: ---�._.i� _,..._----��----._.._.._. —___...—..__.._.-.-- _.__,. _...- --- -- - -- �Fltion #: 2 ;• D�;Scri�fi�n: _ Lifp Ann�it_y_�_, _ ' J � f Em��oye�;'s S�e�ria#ur�: � '''.; _ �� �, !�� , + t 1 �' , ,� .. , �_ Cate: ' - �- ------ __ _ _ _ m I�takirac�dpii�r7 3,'fill ir� �ieneficiary informatic��� ar�d sig� beiow: _ - - . . . - - ---- ---- - -- ---.. . ---- ------ i��:ti;;�-i �= ----- Descriptio��: .__..__ 1�� Yaar Cert�in_and Lif� Arrnuitv ----- i�Jl`,J dBSl�;a.l�.t�C.. �ier...�irl�r� IS: Narn�;: ��it cf Bi�h Addrzss: Ph,�c�ne PJ��m��r: Ernplr�y�2's �ic:r��i��re: 5c�ci�l S�curit�,r Nu�nb�r: C�:ri��2r,Ci�cI�Lr7��', N1 F L�a ��: s•n � � i. +. r � f H'^^Cft • � r e„- �rf cir,r 1 „r I] iciii.lf�ft� lJ�}11�71�1 ��� �� �.Ji 7, iiiE iii I�lLiylll iv���iii�i;i, i;�$i:i,� `ii. vc �Ci iy iiisC" .3t.G:: .1i.�. .J�3 t7'.'-'.-.O. . '.r1(�[I 7fl it=� _ �)£'t�l�'1��)[IJfI� . "��, 1:]�sll[ �IIC: .`�� II it.'�"f r+.i1f7LIIC}'_ My �e�ic3ri_3ke:d �en�fici�3ry is: I��31;1tv: ---.... ---------------_._.._� _._. �iD(;Icai ��i:LJ�fty �VLllll'.7P; - ------ l��t�• :�T Fair�h _m___ __ .___. _ Grnci�r �;Circl� OneE M F /';dCff�55 �'fl[Jf1B �.lUfllbEl'. �i���ioyee's Sir�nature: - C�ate: 1f takinc� a�'artial L�mp Sum Payn�er�t, fill i�_ Perc�r�t�� and si�n be}ow: - --- UptiQ� �`: hl�� ...----- �}E�criptian: ,Y-- -- . _f_'arfial Lu_��m Paym�nt -- i cIE�; tc� take ���Ria] lum�a sutn ��y�ment in tl�e �ollo°win� a;nount (�h�GK only �ne): 1Q°Io of ihe actu�r;ally cietermine� WaI�P �f ti�e narrs�al �ekir�:r�ent k�enefit ��7°I; of ;he actu�rialfy dek�rmined v�l��� flf ti-:e i�ormal retirEmt nt ht:n�fit __ 3C�'',�o c�f !!�� actuar3al!y dek�rriiiner� ualu� �f tr,:e rorr�al ret;rement beE�efit I und�rst�nc� my r+�onthly reti�emen? benefit fc�r tl�e U(�iian se ectec� ai�c�vF sha;l br re�luced aceordir,qly. Er�pl�y��'s Signaiure -- -- _ _. ----- Uate: If na€�inc�_� ber�efi�iary ONLY, filf in t�enefieia°-�r ii�formatiQr� ar�d s'sc�n k�elaw: , P��y �lesi�:�at�d beneficit�iy i5: �en�tici�r;� N����: _,_ 4�cn�fciary Date of E3irt��: F3�nefici�r� A�dress: __ E3anefir'i��y Ph[]�e �lui�f�2�: s__ E�rtploy�e's Signaiur�: � m � _ _ ��ne;icia,�,� Se�cia? Security # --- _ _ _. _ . E��;��c ficiary Gend�r l,Cir�le C�ne} M F D�t��. �Tr',I �_ �,:�; � :_�:F:f[��,� Tf-ie �OfBaCl�iv ,I,S'fl..'1�iF?fll';t'c:� 2�:;kr�:.:•:�:�u' . f;��:f�r� �r�r: ?I,:is '��;�, �'aC:�LiNT'Y �.�f� ` d � � - -= � �- — d �Y of r'•- � �_ .. , � �;, G ,�. F'I�l�l.l..ra,a -- - ---- , �17 ;....3 a ti i � ' _ � 3 �_. �.�._. —..�r � r _�� L.. t,—� f ~ � .,_.--T.-_. . _. .,_ .� 1 � l ._. ` .... . .. . , �� �srwh;� is ��rs�rnally known to a�ie nr who !��s �arov���'�d . t �,. � "_._ �:� �' ---_a �,. t , �ava �7otaryPublic5tate �f F4or�i� �'�S ;�e�7tifiCati�i, �i�� wnca di�,�'rJid r»t t�ke an a�th `-.� .°` � r � ~ [: �' �; C�ir�a F Trieste `�� , r. ' --r.. t P �7 � AM1y Commrssion EE 2�743a2 �., . , - , �oP M1� Expires 051tl31201$ '�- -<., ���. -- �% i ir � s� � C7 r7 r�1 L! I I C .. _—�. .., -- --_ .�---�.� _ ;, � I�i1:3lilf�_'j '�-.+��Yr.n:. _,¢ � -7' � `-'`- �---'� ' _ -=' �-� -- _ hvam� of i�atary Printeil - - --- v-. -- _ My C�mr��iss�^n exF;�ir.� ; _ -- � ' ------- - -- `--.'_� �--- _..- - 1=�E:'t� G4i 1 � rr�r17., #99G0_OO�Ig �iIL f�arne: Pensi�n En;�'rlePx�4r7t C�7pticr7 i=rarrri I i ,:V�ernher i)arj� ;���n�� �7;e�c of 13irtfz ri�c �tt ltclircm�i�t F3enetici��r'�' �ata N:tio7�• �)�l[i� [10 �3E]-f�l :`'1Li' i3l �EC1.]["�]t7L'�I1i l�etir�ni��# Dat�� 13ir� I)aac: � i.f"i171I�),llVtilll ��iY[L' L:i'ic�ti��v !)at� �' i`� � � �. UI7�7lZ�Lk[IC)[3S ]3�l�rs;til �itw� of ��'�e�irwate�• �m��oyecs' Ret�renient Syrs�em �eneti# Estimate xot.�.�' nu:�.+�Nt[) 1(]i311]9SZ fi[} �'cars 8 1bT[�nths 1 []a+�� J1�:1�12�' �I[JS:i�,'i() ll�l/3!)1 i °]5(? �i3 Ycr�rs 7 17[ritlhs 1 !).kv� ii2i 1 [!! 1 i)l�Ci i1617+31?1}i3��.,��W �-�2�'�t�� f}'71i16 f? 1113 - � x �5, 313.3'I � i}.0(i � {},�}[y 5a�eial 4ccurity Nr�. Si7Li�3E S�c:urify i��a. ftui<alarrrislri� �i��uuse ;i t�f'�ttiilclrc�� �indcr I �; {1 Calc�ileitu��3 Tyar� 13c.or�lit (irc7lrp I��.tircF�iun[ 'T't�pe .: �)})[EGI] �IV'L`�@:Cj ' J� �3 f i E il J,.,��:.L! lI7}7"�LtTF3 7'�atal.lYlcii'cbcr �crvi�� • �i�„_ ., ,_; I�annui�3 li3r 13c3�ciit r`� 2.7�"/r� *?7.3�3G1 y'c�rrs *`5�5,31'�:39 -` ' :,,} I� Ifrm [rF P�t}�n�cnf � rector �iarE�3�<xl l�o�•m � E .l)[��)(1[1 �id1�;�ti �.I��U !�I1]]ZLIIII+` � I .U�% j ] ] I [i '�`�a�• {.'4rsa�n ��3ic1 l.if�° 1lnnkoit�• ` � . 1.f}Gf).i � 5Q"-�, J�1in� aEnd S€a�vi����s' 1.{}�c)ig -�",;� .lt>ii�t ;u7tl 44�rvi��c�r 3 .f7ii 1(}7 1{itY'�� Jnint �li1Lj SLIF�'IE�ur ().9?�:�?7 � (D � � � � �,stiinatt� tilor� Hso�.�rd�aus - C�a-unc�l°ath�rcd �'YC1E'Eildk� ��Cti1"�Ll1Y(-ill �;fl.OU (+f}'/�) z7 Ye:ars 4:I�T�nihs 1�J I)a��s lwlqrithlv F3rncfil i'trtenti:�� f� iV�crn�icr 7'rr i3eEZc#�eiarv b3,�7 ] .4C� N,`11 �,3, i �5�.�� ]v?'r'�, �3,���U.��K :�� `A ��,3,5l:i.4ii .`,4i ] . i �iG.?3 �3.475.17 �2,fi{]t,.:,�t �3,3�?. ] > �3,.±�2. I 7 ;! ii�• �"�tl!.,:.i���ls�,,�.�i .ir� Ic�i illi�;r,r:tii�•� S��a:,��.>>c., �:�n�v nntl i.ii�l�ss ��:i�t:ri�iisi:trl��J �;!?ict;ii�i'tih���ticl r-4�t fr�: ;`c�.ilC'�I ;�ti dint3l r��.ti��lls. �� fllti ti;�ale�el�i.tipn iti tiuE�iccF tt�� Lti��i`rci;lit7[�. If`y'c:�u �ICC Ur 17�C:C➢I�T7� t9Wd1Ft; Qf ['1TC1fS hl] T�]i i�ata il�.at ����1�; l4S('.Cf, T}li�. �zllc;tilulicros (haE 4���rc 113�LCIti, t�F t�l�' ]7i�.i17 E71'[)�'[Slt]I7S iftat E4'L'CC: �1���)[]i;i�, 1( Iti }�C)i33' flS��c�rsil�ilit}' Ef7 C:C7�t717C1 l��C ����li! d!(�]Z71C79tiI]':.lilll'. ���7L` p�s91] �l�lti 1�71' !'P��ll !i1 I"CS;[}'.'c;l' �Tt1171 4''t�L! 1R[]l[3LIf7�ti l}IiI.0 14'CE'Ct ]�llPCj lC! }'U{l 117 �il'V!'. �xxx�:�:��,:nx.<����r�r��:�:��:*Knx�x'j'�]IS l5 ()Cl��' �f7 FS�lft7�]�C x.+.�'r,�':x>F��:;i'r':A:k.�::;c�l•�;.-!:x7'r9c9::1•;l•:f:�:A {'rf�5 13c•i:cll� t':il�tel:�lu+. j[ 3�"_'4j -@.il.�!?4.1.19;i1�6 l I�<<J9} lf??� ?8� i,'14�'5113 �:il�:5fl f'�L1 -�-r ,.. � • � . , '4. I 1�I LJ' 1 L� L L f-=1 I\�'! '% 7'1 I L 1�\ �MP�(�Y�ES' SEPARATiC�iU PAY PREFEP.��CES - <. s,,� 1 ,� ._'�s.-'; G�. � � .. PR���R�NCE #� E;1���Ic�yees ca.~� r���eiv� � i�imp surr, p��s���nt E�r' ��c��ti�n, fl��'tsr�� h�lic.�� E��y, s�ck '^�ve {n�entive, k��n�.�s c#ays (if ap;�lica�l°i, �nd 1!2 or �CCf-JcCI �IGI{ I��v° at in� iirr�? af se���r._:tii�r� frr�rri the City. Th�r� t�vil! �� ��n �1�riuviion fc�r pPr�sia;� Tr��r� ti�is I�.irr�p su�7� p�yment r�c�r 1Nli� tf,�is a�r�o�i�t c:a�int �s ��rnin��s in t��e calc�if�tic�r� c�` t:h��� pensi�r�. Th,� last d�y of �•v+e�rk wi!I �e the termir��t���n ��fp �nd ��nsson k�enefifs ��vill be�in th�� fol�o}�h�i��g mcanth. PREF�f��htCE #2 Lrr�pl�y�G ��i� exten� :err7�ination datp �';� �art nr al" of t}-ie tif�7e �i�i� i�r �•acati�r�. fl��ti��g nofir�a_y pay, sick €�av� inc�nti��, b�,�us day� (if �pg�licr�hlr}, �nd 11� nf accr�aec� sick IP��e. Empl�yv� m�y cr�r�ose t� r�in o��t �his iin�v in arr;� m�r�n�r, Cal�n��e ��vil' �e paid in � lun��� SLIIlI C3f� ?rr�plc�y��'s fina{ p�ychuck, T�rr��in�t�on �iat� vdill �,� ir,� fi�a��l �;ay oi �x��n�E� tirr�e. P�n�io� � b������ts wil! ��yir� thc foEl�vuia�� �ar�#�. _. ........�.�,�.r-:�,:,.._ _ ._. __ _ � ,.__�..�.__ 1 .�C�`c��"'�, hti,a�.��',�:'�'+� , an er�pl�ye� of thz Cify Q# Cl�arwater, here�y af�piy f�r p��sion f�en�fit� uncier the Gity's Emplr�yrees' P�fl5f0�� 1�1an. I h�r�by certi�fy �hat I iuliy unders�anc� ti�e prefere����� nffrred �� n�e. I�hcas� �� r�tire usii�g separatie��n ��y �refer�nce ��� _�r,�i v�risf�� n1y r�2nefits ic� }�� calcul�te�i unr��r tf�is �r�fer�nc:e, Ple�s� �,s� ���y I�av� ir� thr failc:wing mann�r: Run Ouf L��p Surr� VaCr��IGiI �-�'� VaCatIOIl S1CiC '����t��"S b�n�,� r,����-� �`�� sick �,�`.� float�rs "'� ,.' `� ` bOflL9� �lC}UfS ! tfnd�rsta��d th�# my pi��ferer�ee ca��noi �� cE�anged anc.e thES fo�m is s��ned and t�at r�y c�er.isson is m i; G v��.�c.ab!�. � �����v��'s sa�rva i u��: ;�. - , r _ � , 'J'JI�N�SS�S: _.� . �� - - _.�. , ,�.�. '} � .�; SL�GIA� S�CIJRITY ??: F��]DR�SS: � �;^•:t-...� ..,'_:� ,- r..i� _�L � -;'_ � -: �, 1 , . . t � . , ... ;• t 1 . �:C_ i . V..... `'�.. i . .: E � �, .� "; _...... __ . . . e �.. � . .(_. ... Pf-IC}NE � ' _ 1�)- l i` :�._ �- ' t `'- Di1T�: � ~� z �'� �'`. - �-, Re+��i��ecl 1rU2 1'orrn #9'�Qf;•J��+8 File ��7rr�r En�plcye[- S�;,ar?fic�n Fay F'ief C: I 1 Y O F C L � �-1, E� VilEl-I' ��� �����ar� �r��ri�r��.�,��rv-r �;��ric��v ��c�u��r:=a�rn N��-HA�Af��?O[JS L7UTY FMPL CJY�� _ __— - _ _.... _.._ _ ---- _ i, �C��,�� !'�.� b_�t 1 ri E :�o her���y a�a�;ly �a re..�°i�,'e: 'ti}��r�e;f�t� vir����r �r��, ; [.;t'}! :;f 4�'''�?rfl�'dd}?.I" ��i��f�� �illl�i�0�`��'ES� P�r�:ilUil ������� in ac.��rd�nec� yvitl� th.0 �C7��G'ds�If1C ' I � _ �:: [)��e of Birth: � ' ` � -:� ; 1`° t `-'�.�_'- -_..---- ��enr��r (chrcl� �ne;r. �, P�1 F . - ` �—r� . Jon Class�fi��tict� �,,:'�. =it�_�:•�.�'.�. . �_._.__{ �-�:c. : � ,��t- _�. 'it..� .t �l _- -i- 1� -���.'- '� f - , ,. �1141�1Cf1 'ti' e C__ i t� � , � �G�:uftrilPflt ;J... � -�' �4 �: � 3 t'iy f — �---.— _t ��� _ . � —�� f��!e of Hir? ��.__ ! __ `L ��'.-:ir,.__�_ _ ----- [1ai�`: t7f SP���`�fii0�1: _�'y+ � :� c'� ��'�`��'� ��-�y — E�er��efits �.ff�;cti�� CJ�i�: _����__-�%:sLC�'i;�� . . S�oLise's hl�r���: �i�o�ise's C��fe af Birti�: _� - --- -- -- _ ... _-- S��use's G�n�er �Uircle one}: P.�1 � The ty�e gf pe+�si�n f�r whi�,h I am a��lyinr� is (cl�,eck only o��ej: _;._�_ f2F��tlar Pension based rF� y��r� nf ser!�ice Juk�-cor3�ee.ted L}is:�bifily� �c.nsior� --------- �J���-jak�-ct�=�n�cte�1 l�isaf:�ilitl Pensiai� i he C+[y of ��e�iti�+��fier En�rloyc�s' �en5ion P!��r� �rc�vi�ie7 rrsuftipfe �pticns tc� f'lUn F'art:csi��nis ,a� tn fhz m��nn�r of tf�� E�2nsian k��n��fit p"r3�IllEfi�. L7�]�IDII ��el�rn�- r�F�r�sFnt��= thi s�andard or nor�;ial fc?rm �i re;k�r�rr�c�t k��nefit f��� €����ici�ants ���iqi�l�,� t� rctir� �rie�� io .J��nu��ry '1, 2C�1;;. L�oti!�n � k�e?o�v �epr�s�nts kh�: s�� nrlarci �� nnrnz�l tt?rF�� �.�f r�.tsr�+7��ni b�rrefik for Particip�nts eiiyiE,lc tn retir�� {�ftcr G�c���r����r 31, 2C�1�. -�h� nth�s- ��tias�?I fc�rn�s (�3- #� J sh�!I �� cc�r7��uE�J kr� k�e "t��� Aetuarial Ee�uiv�l�nt �f kl�e r�s}a��ctFVE� n�rrr��l b�nef�t. O#�t3ori 1- Jc�int and Surv��or Ariniiity [D�ILY i# elie�iiale to reiire prior to JaMivary 1, �fl'13� A,r� <���n+�iiy� ��ii� mo��thiy ior th� I�fe cf ta�e f'ariici���r�t, }�+�!ll-i a"10i�°�� sur�r�war a:�r;uity ��ici rr`��nkh€y ac.-r ���E�r'iod of fr,�e '�P_c�f5 fC�i�t71r�,`ffl� if1E CjEa��l L� trl�' F'�f�,'Clj�c'3flt rC] t�1'c.' i]C:CI�.'�'.Clclf�yr, jJ[.r'iVIi�E.'� trlc'3� fCi��C1�iVl�l� SC1Cf1 ifVE yE:ci� �]Ef�IC}rv' trl�-�' SCI�'u'IViJI �,?f'.f1LJltj1 Srl��� �t74' I-EC�L1Ct�.� t� "��"�� Vt tr1P. �)iBClilc7� .�1,11'�lIWi31 �}f1f;Lllt1� c31T1fJLlflt. �7�'.E'. e�E.'Ct1�3C1 �..>�� {�]� 1;;3� (,��� T�i� �aftlCl�ic�ilt'S SL]�VlVlrl� 5�7t��152 f�C�l`J°S tflG C3,�^.Sli�fl'cdtEC� c3filC}Uflt F��f' fil�; I"(:St Cf ��IS�'f1C.-'f' �li;' UI� Ufitl� �"i`?�SiIE' fI?fl�c]CfI�S. �f Ilp SLIf"VIVI�1� Sj.�pLlSP_, CiE�7�FlClellf ChliL�l"�n L1nCi�l ��1G ;=i��: Of i�3 Sh�l� hE: d2Elll�'Cl �J L7� �hE ���1£;flCl�ll"iJ aftiC� i�CE;IV�. �he r1t.51C�31�tc� �RlC7urst ur�til th�e age o€ 18. [Secti�7n 2.3��� ;:�j (3j �i,d ��CflOil L.J�'� �bl f}7l �tion_ 2 — �if� Annt�i� ' f�� � p� '� g I �_'�: a ;h�; Parlic:F��r3nt r� � t: �'�c: F�arfici ��nt C�Ct,I'JG-'S I�kSillEl- �i1SIC}fl c`3S �,?fl �3"� 1::,`>�l!'. �I.F,•;; ; C?fl i�l� G��iil C?? �c'IlF fi CP�iSE' ���_:���� 2 4�f, i�.;� ��-�_i ��cti�:, � �z� F�� ;�� �, 1.� � C1�tion 3- 10 Y�a_r_Certain & L.i�e f�nr�t�it^� -�;n��s� deaic�raat�: a!aei��f�ciaryj rhe p:�rtici��r,�i r�eeives fiisifi�r �k nsi�n as :onc �s h4+sl-;e lives, If th� F'�r�ii�wipar�t cai���s ��f��re 1�G rr3�rithly r�yi��E:;�ts ht3�,�r; ra��a� �-i�a+�e, fih�w re:maini�;r, ;��ayi��ers!s �� tn �he 1�[} F7%3v«��nt; are :r.�i�v t�; l�i5r'�,k_r �unefic��3:�' r�r t}�c� c�si�i� �# h�sih�t- �:�n�iiciary is nt�t �li',�e. [��ecti�r7 2.��4 �,bj {21 � :'_ ; d�stian 4- 50°l� Jotr�i & S«rvivor Arinuity -(must c�esi�r�at� � k��neficiary} i-f��� Pari�����r�[ r�:cei�.�es Izis.lf�C�° �€:n�ic���� as 1orr� �s ne';,h:1 lives, If the F��ilit��r�;�t di�s first, tl���� Y��-:n���ir3�ry� rwcei�rr� =�(i p�'rce�7z e�` `.17�� ;�r���si!�ri €c�r ;hG ��:at �f th� r�e��cficiary's lif�-, rf tf'�� k�er��fie:ia�Y� �i�.s ti�si, :'?� P�rt�c:���3nt i�ay �!��nt �nGtflE'� f'E�f7�'flCacsftj Qr iilt3� i,(�fl�lfll.lf �O �ECEI'J� t��'{��-�i �.`,i �ll�;�fl.�f` �'E',f`ISl��fl nil�:f LlF1G?il �11`.:f;lr� rj�'��t�l, h�f?�rl;�, ',r�ca ��+?i,;iifJfi �.=+�� ��J} i.:7� �i.. 3.� ��tic�ri � - 75°��� .ioFni & Surviaor �1zir�uir�� - {�us�� �le�€�3i��t� � h�s�vri:.�iarY) Tfir, L-7;�r�;�,i�7�r�t rE.���i����s r,is.�he; qerisicn �s 4,�n� as he?�al-�=� I14`�S. If ihe i�'aPfi:ci��an; ciies �irsi, ih7� 'r�E:fl�fli�l�f'y' rec��ti�Fu�� '�J �.r'i,,.�a^t Ui ir?F �C7P1"1SIOr! li7f tf"�' .!;:ii. .� tf'1�= f7C„lc'.�I(�I�^'�S �^'fF� �t lfl� �1�!?G'?IC+.c3.��j �iC�. :If�i� tr1E ��c`1.'�I�.I�Jclflt Il�c3j1 °�E:C;'I .�f104�1�f �1�'�1�'ffGl�.'3f:}` Of f1-1�3�� {;C+1CIf1L1C? :l f, :�:IJ. 'ftrl` , i.'r F�I<<'f'.°� ��^Ilc:,l;=�i� 7fl(I LI�5r1fi i-iISIFI�f �.{erttr4 �_ .'.'lr���lY�. ':�;�c�' ��E:ck�on 2 �'2? (h; (,al ��. � 1 a�tio�� �- 1a�`�E� Jair7t 3� Survivvr Anniiity -�r�,��st ciesic�r��te ��cncfici�ryj T"i�; F'urii:: �::3��1. r�c�;ve5 ��is h���r .�:i�.�i� :�:s I�.�n ��s f �..rS:lt 111�C�. �f tflC: �,'�.ffICIL�.`� �C �'i_`-� il _;,. l�iF' i)t211E' 1CI�.�t'�,' ii..;•!IL'F?7 1_,[J �erccnt oi t��� �e�-,ssc�n f�7r t 7� �e:�.t of ChC: ki�?rl�flci�n�'s lifr�. if ;f}e �.��nr`i;;i<�:, ,' �_ f� �[. �li? I'UrLr:F���rit ��'��y �Ir�ct c`.iflC7tilC,f' C7t:f1Ef1Clc3f`y' Ul" f'f"I�i'y^' C�fltlil�l� t.7 I-� CEIVE �i �L''LJ�%% C)f r,IS�fi�!" �7Gf1SIG�'l �f'C� L1g�Cfl illti+ll�'f ���'�3fr!, i7��"I�;il,5 �.E�35E:. �;7f'C:IC]fl 2.42d f ki? (1 � �. .i.� O�tion 7- 66 r/.`%� Jc�ir�t 8� 5�irvivp� Ai�rn��ity - 4i��aist c�esignate a be�aeficiaiy} Tht P�rtscipa�7t r�eei��e5 �llSrll�::r ,,ensi,�:r� us I�,�,� �s 1,-'shr li���es. If tf��e Pa�tici��a��i �:e4 �ir�;i, tl��e L�r��•€iciary r��c�iv�s 5�'I'� percen: at tl,�p pPnsion ���r tf-�e -�s� of i7� h��ivficiary�s li��. ]�'t���e b�np�i�ia�.,� di�s fir:,l tnc: f-?7�k;�;sp�t�t m�y �Ir•.�:k ar�ath�r i�en�f�ci�iV �r ni�y con#inUe Eo receive 10v°�� r�f h�s.!f�er pension and u���� his+I�Lr r;���t�i, henefits �:.�=�se. [Sectian 2.=124 �bj {2i �. i.] Partial Lum� Surn Paym�nt Qptioa� "�. �art�al Izir:�� s�arn �2Yment e�tu��� t�. F=iiher t�r�, ;�er� E.nt !"• �°r4 j. t��venty ;3�rc�nt j2�`:��;�, or thirt�f :��_rcer�� (�L�'I�j �f 'he ���tuaiie,lly r�eterr�`iincd value �f tnf- ��c����al �eti{err7er�t her:efik r��_ie ti�e mer����er Fr��y ��e eIF�: tec� in corr�bin�tion +�vifh any of #��� �ptic�ns in+_iicair�� a��cr�p. If � m��r�i�sr r el=.r��s, 5�i�h ��2�ti�l luiri�! su��r� c��s�ri�utic,n, the�« tr�e i����,ritl��;y rFtiresr�e��t hcn�fi� for :h� ni�tion se��:�tUr sh�l� f�e r����.ir�ec� a�corr�ir:alv tf��reaiter. [�ection 2.4�� �; b., j.?} ;�. 4] I h��e co!�si�{er��i thr-: varinus b�n�fi� p�ymen�. n7et��n�is �.�nc�er s�.ich Pl��r1 �anci h�v� nle�t��i tr_a rec;eiu� �»y retirFrner�t ben�fi�s as rnclic�te�i� !�eic^.n�. {�*Jr�t�: Dg�tic�i� se!er,tion ta �e irdic�ter� r�ok� by �f�ir�l�er anrJ C1esc�;��tior�.;� !��rirjerstanc� tf��t :��cQ my firs± �ensi��� c��erk is rec��ve�l, �r�y tlecisiot� c�n il��s ��atic�ri ss irre�r�cabi�. lf takir7g C3�tian_'I sic�rl_i�elow:------ t�p`;on #__1_ L�sr�riF�t�on: _.Joi��t and S��rv�+��r An�uit�!-__ �^. ����pl�ye�:'� Siynature: _�_f' ,. -=---- --- -- Date: `t.-. �'_ � 17e�����ent chi�c�r�n und�r th� ag�� c,f 1� an�i rc�iuinc� in rny �custho�d �re: , ChF+r''s N�me Gender �at� of Bi:�h � , __�.._.---------..- -__...__.. . - -------- -- - i � -_`=-_ .- -.-- _ �.. _ _ = ' _ If takin�_Option 2 sigr� helow: �__.___. - ----- - -- i��_�tinr� �: __2 D�sr�r;��tior7 . _ Life Az7����i�y � �,��Invet s `�t�n��*�!re: - -- _- -.. _.._. --- f�at�: - - - �._(p _ _ -___ - ---._. .. ._ — -° _.. ---- .__� ---. . ___ -- - _. . -- t#t��:ir��_��tion 3, firEl in_hen�ficia.r�r. i��torr�aiiae� ar��i si�i heio�v_ I L�lj7:lr�fl f,t: .3 L)escr,��ti�n: -- - 1 n Ye:�r C�rf�ir� aY�d_ Li�� ;,n�uitl__ - Pv4y dr�ss�tr,�+,�ra ben�r"I:s.?ry' i5. [� r71T1 �",�-' — -. .. _ d._.....�.. --- -- I i���� :�r t����r, I-- --- - ---. _ __ _ ° _ � �1'�,riu!_���3 ��i-,�n�; CJuir�:�er ____..-_� I�171�f�yEw � �?I��f'�lUl'�: --- i.�_ _..._ •_ - --- _. �C�CI,"i� �•L'Ci.il"lipl �`+Jilf'+.lf)C�' L��f?�Ct ��,.�I3L1° �.�'.�f���i ���� F .. . .-- . 1�:7 i� � �a .c-i• - r^.r. - A� t. - - L; - �� 1� .�:..;. ii � � a �1 n ���i�i- �� Ce1lCIi1C� V}]`liGfl v. :?, l'7,c7i t. �ili iii �.!Niivil vLiiiii!K'.i �`ic�S�:e' �i `` i .�J�'y` �IIiC�{'7e3 .�.��f::; j:C�.� J.� ... . U��ti��?r•: � __---- C)escri�itS�r. °I, ,ici;�t anc� 5urvi�rr�r F,nn.iiiy_ f�Jly �'esign,�teG� buneTic;iary is' IJ � m � __._ _._. _ ...�.� _— -- f�ate a; E3ir�h: . - -- --- - ---------_ tiddress PhrnG N��mbF r: Cn7;aloye�'s S�anat�.ire: __ --- SoGial S�curi;y �um��Er _ --- --- G�nr��r �,Cirr;la C?riej €v1 � ❑at�: if takir�r� a Par#ia[ Lurr�p Sum Pay�l7ent, fi�l in Percen�a�� an�l sir�r� �elow: f C; t�an #: N?, C)�sif-1�7i101",. F�dr1�I Ll.lrrp Su�'� f��'vr�Fnt_4 _-- -- i eleci ia [�k.� � pariial 1�3rr�� sum �aaymrnt iz� thE f:�ll�rtival-�� �I�lLUflt {C:!:CCK �.ii �ha r_;r7e}: 1�°I.� o# the actu�rially d�•:rr�l�inz�d �r�l:ic of the norrnal retir.�rn��r�t benefit �?CJ°fa c�# the a::iu�rialh;� d��er���ined v�alue �f the r�or��-ja� retirerrient ��r��fit _:��J�,, o# th� ;�ctu�ri�lly d�t�rmined �!�I�.�� of th� r�orr�-��! retirerr��nt benefit 1�nrierst�nd my �r�o�thly r�tirer»ent benefit fc�r t�e Q�tian se"PCte�6 c]b6VP_ shall '�� reducec I Emplc�yee's 5�c�nature C3�fe If namio�y a b�neficia_ry C3NLY, fill_�n ber�eficiary infor�nation_and si�n �aelow: j f��l}� riF�sigr�t�ied ben�fic.ia ;� is. �eneficiary f�air�e: __..... ,_ �3ene`iciar�� ❑�te of �irth _._ F�ene€iGidry P�dcJr�ss: [�.�neiicsary F'hor�e Nurr���r � �-iF�lr�yee's Sign�tu�e-'_— � __.! I I -- -------- I3e«eficiary 5c�csal Se�uri{y� #: � ___..�._a..___� Ber��ficia�y �er�d�r [Cir:�:le C�nk�] Nl F ���fc: �i l,'-,:'� ��.�F rL{�F:IUA Tr-,� r;;r�go�i�g ir'Si.rl;�l?C?flt L"J�75 �c.+tn�wle�ued �v`�rz ir�� thas �: ; (.:� l_1 N T ��` (� F , . . . 3 • -- -. „ -� ' � ` - � 8V C>f 1 �: �,i a 2 (� �1� �._ �_. , � � i r� � L LA s 4., - -- - , __._v_....__...._._� -- - .— � . . � : Y-, , r��r� x� t• �� � ;: -:� .�� , � �,,�_.� :,... �,,d�'fru� Npt�ryPubficStatEOf Florida 4'J�1Q IS �?r;5p'la��]�` iCf1C�VJ�1 t� iYb�' �f �"Jt�� has �rD'�idW'!i v�__� �,Ji� -- -- Gina F Triest� ;ti , �' l , ti+< �:_ � <� � '` - • • ' y,�� ,[�� MyCommpss�anEE20A342 �S I!�'�,�?faflGd410€� 2f1C�'dVilG �I�iC.�IC� flDt iai�c ai'1 C]�Ji�'I. " 'j►oj �d° Expires 06f4372016 � . ` i - � r -:�`'�. Not�ry Pu�[ic ' �. tti�y__ -- � �� � < ,. ---' _--.. _ . . -- � --- - -._.a��_.__._.,. - - �,... ----._._ _-- [Ui�i:dl:ira� �� � ' i �C. `�-- . C� - �� 4`_i �'_ � a � } .__ : � ° - :_ _. i��me r�f �Jct�ry Prir�,F� .... .- - -- My� Cc����rissi��� �xp:r�s �„ f � 7 ��, �.. . .. �; ;� � � _- , , � -` � - - --- --- - �?��i t7�,''1;i I r:�rr'1 r��1�a{]C}--l.)0�:)n F ile j`�[ :�n��:r: Pfif" =.;(.?�`' E:nii:lerrlF�rli t=?��,tir_�nn �=r�� �'i i !17c�r�t�er D�ta Nai��� f)aac ��f�lii�-th At;l :si ft�lir�in�nl i�['[le�1L'lat'V �'dfd ?tiltim� I?��lc ��f�13iEth r'I�;c al ]�clircnx:ril ��etirernent DaQa llirc i]�ilc i'cn��if��i[ic��i i7al� I:I�l�sli��� [)t�(� f� 1t' � u11iE'lI�LIIl4)E?ti I i�t�r�yt C���rmE�la 1�or E3cncfi! !1 City vf {Clearrv�ter Em�l�y�es' R�tirement 5,y�stem �en�fit Estimaie .1(�31iN NIJE;�;F;�, [13111:t1 i 9�� fil 1'rxrs 2 IYlunflts 2!3 ❑a�'s I tH"2f,1 i 987 - f1b'�dll2013 (�; v�S � � �''.a�� 4�� f3(rf}112[I13 w 7�,a14.59 � r�.c��� � 4.[if1 Sociai Scc��rit�f i�o Soi;i�] 5�i'tri'ilv Nc)- Etcl�ttino� �hip r! r,f child�Gn E�n�icr 1�{ C aicul�tticj�7 �yp� Eicnciit C�rc�up f��iir� 3��4nt 'f'�i�e f?;�ticrrl:�iccted ]'arti,j[ Liiin� S��m I'�tal.11�:zili�cr 5�r�iv� 2.75"/� * 25.5EI72 ,ycars * $7;,SI�J:�+'3. ' ;, ':: .,,., [�i��-m a�f Pa�•nacni I�act[n' ��rrmrill�E3ri2� � l.il(]U(lil �in��lc I:i�fe rknnuilv� � !.OUE)f�{) It} Yv;i� ('�rt;iin E311L{ I,i�C l�E717Yi]iy . � �, �' {),q7 [?y F�:.:.:. � (D � � � �! �-XX-Z3�17 I;titim�itc �trn-1 f:�;;xrci<auti - 4: randfatlicrccl i�csrn���i idetircrr��nl `;,il.E.111 {I) `%u) 2� Ye�irs 7 Ik''�[rnlhs 5 i)aVs f47ointlaly l�rnrlil �Pa�de��iral 1'cr hlem�ker l'ca l3eneiiciarti� ��:'I ;f).11{} NiA ;�d.�3I.}.{10 1�lIr1 S4,.i[}�.E]3 �'l.�i �� � �'li .. :Ili'.��. l�l..l7�;!?,'l't� �il'C I;ll 1�Eiltil::.11l,'l j117Y,`i�,-.1•.� �.r1�1�4 :II1�f lif;�._ti. i'�i1i111ilYlkl{ t.3ICS.; i`i �ii �� ., .� ii�iliil�i; 17i.�i f?t' i`�'�IICI.� :.Ir. �flldl� 1:.'itl�l:, 3 f734 CCIICLEIelL14][] I±. tiil€7��CLii [C7 C.(51']"CtL[l.lil. �j �'[�U arc. c�r bc�oi�ic• ti.sk~,�rr Of i:1-1Y11'ti I!7 �}1C C�:i�:l L�1i11 �i':1:ti tatic{�, II]C CtikICL[I'�lllt]Ilti t37L3� L�,���.rC m�tdr. c�r [li� I7��111 j3iUVltili1115 I�1�1L AL`L'1'C :]�7�7�1CC�, 1� Iti 'r'1)llf 1Lti�7{7P]SIf)101t1' L(1 CUi]Ii1CI IE]L' �'?��l[j Ei(�1T]1111titf�Cltt1]'. ��lC k7�fl11 �1:1ti i.��ti ]'I`�h11 �U ��ccuv�r lrci,i� ycni �33n����nts [h�it �vcr�� }��tic� t�� yo�i in crrnr. = �: a * x x t• :� ,� � � � �t k x x � �; :� �: * � :r � ,• � �- �k � `�' �-i 15 i S �_D i1 � �y' d11 E �, S �I I�a r`I � � 'k X k .' J' 3' i; �; � :F �; 9,- � A k :F x x �; �k �c x �: A k < �l � [;Itti 13�nrilt [':31cc�l;iturf['?'?��)}- P.11.4'4;.1�3hf,Ce{154l711l13�: �?(, 4rlfr��(➢11 i?:,i?:;? 9'hi i., i i�i� v i` +... i� a'r'-�. � i v�"i r-i i C � i �nn��o�rE�s° ��p���T�a� �4�r ����=�P���c�s y� � t J � ';,p _� , ff ;..1- -a .� � � y -- '- [ � I�REF�RE�ICE �#1 Lmp��yces c�r�� re��°iv� a lur7�p ;�urn �^ay�r;e,ik f�r �v�;��:atian, fIC]�tlf�� ��OIICi�y p��y, �i�k €�av� I�1C�n�]�r'?, �7G�flL1S Ci�]�S [I" ��FJ;ICc7bI��, ��nd 112 r�f a�cruec3 sick I��v� ai ;��� ri�r�� of s��arati��� 3rom t�.� �ity. T��r� wil4 �� n� c�d���tion fi��r ��nsi�n f�om this 3�_ir�p sum oa�Jn�ent nor ��vif� �hFs amau;�t cnur,t �s e�rnings in th� caic�alatiay� o� �l�e p°nsio�. The l�st ��,�- c�f w�rk ��vill be �hu termir,ati��n d�t� ar��i pension �e�a;its ��vsil b��in ihe �ofl��,�ti�inc mor�th. �'R�FERE�l�CE #�Z ��r�ploye� can extend t�rmin�iian dat� by parfi or all of the iirs�e due :or vacatFC�n, flo��ir�g noliday pay; sick 1e�W� is�c�r�#�ue, �on�.�s days (if a�pEECabEe}, �r�d 1f2 of �ccrued sick €�a�r�. Ernplo;�ee m���r chacae t� run out t��is tirne ��n any �n�nnar. Balance v��ill b� �ab�i iE� a It�rnp sum an er7���l�y�e s fir��l pay�c�e�k. Terrrsinatr�n �a�e vvill be s�e »al �dy cs� Gx��nd�ci tir�E�. ����ion u�n�3it� �ti�ill ��girE th� fc�llo�yvia�g month, 1 ��'c ?�1f;r� �; �. �i �-� '��; )� E:C� —, �n em�layee of t9�e City Qf Ckear�v�ter, f�ere}�y apply far pen�i�n �enefits under t}�e City's ErnplayPes' Pertsior� Plan. I h�r�by certl+y th�� � f�:lly und�rstanc� t��e �4efi�rences offered to me. I chaase to ��tFre using s�paratian �ay �refer��ce # ��- ar�d wish my benefi}s t� be c�l�,ulated under this pr�fer�nce_ Please ��e rny �eave ir� the Fpllo�rring manr�Pr: f��� Dut L;��r�p Sum vacaiian � :` �3 .� �' vacat�on s�c1c floa�ers �onus h�Lir� �� sick ' ` r�: fl�aters -� b�nus �ours I�inr�;rsFand that rny pr°i�rencP car�nat f�e cnars��d onc� this farnl 4s sian��l an�l tha� my deci�ion is m irr.���cabf�. - � �.�PLC?YE�'S S�G1ti]1�TlJR�: �1 �-'��- � , `� V`JI�T���SES_ r ., ` _> - - _.. . � S��IAL SEC�?R1TY a�: r"IDQ�E�S, `.� �-�' . �i l:°.� :�' ; - tJ /-�hi'.,`:t',,, _�,�-�+�-d ! � `�; `,, � -r. "%��� ,t� �: f � _. � �-I Q �1 � � �r f� ._.. ;� ,� , - , dA,T E: ��� ; ,, ;` 4� ���J�S��:� �:�,�z �Orn' �GCs +�-i�I+L� FiS? Name: �mplGyee S�p�r2tio i P�y F'-e; r"-� r'V r��� �'ti�l�S={}.�I!�+��� ��.�rs�o� ����i���r��NT OP i IC}� i�EQ�.}E57 ro�i� NC��I�H�Z��DClJ� DUTY ��ViP} DYEE �— �� im.v�� i �! .7'uiN � i r'_f d❑ he�eby a?pl`� `L� f:::CE?IV2 �7Eil�ilt� UC'i4�E� t�i>: Ciky �f ClearUdater Gen2ral E�7�,�l�yees' P�nsicr F'1,��� in acc��;r�a:��e ��^�iih t�i� follo����ing: r f'�., I �;tz f E3irF�� .� ��'�I i�� _ G��l�af fCIiCIG' Gn�): N1��F� Jo� Ll�ssir'ic�ti�r�'-'� ;��� �-, `�: ��•���'��� F' _--�� . � ., R., .� i �IVISI�tI ; �'�`.' . J,� ._� '.� , � y -ra ,. Department _ = ,, �- �-_ .� � _--._ _ _ , -� Date af Hire. fr t'.',� � r°� �s :a D�tP 0� S���r�:l�fl: , +xl:�'.f i%.-� _ , � r — E3ene;its �ffEeiive Daie' `�,'; !!.�� ------ 5aouse's N�me= --- . Spo�se's a�t� cf Birth: _ 5�ouse's Gend�f {cir_l� anej !v6 F � The type of p��sson �rar wl��ic�� I arr� a�plyinc� fs (cneck �r��ly or�j: �'"�$ Regui�r Per�sian wase� or y��rs af s�rvice Jab-con,��cte� Qis��ilsa� �'ensi�r �� 1Vcn-jc��a-connected Disa�aility Pension Th� Giiy af �I�aav+,�ater EmpEny��s' �'ensian Plan prrs��rides mult€pl� opt3cns ta Plan Particip�nts as tc the manner o# th� �e�sian b�nefit ;�ayment. Qption 1 b�low re��rescnts the stane�ar� r�r �crm�l form �f ret�r�ment b�nefst for ?ark�cipan�� �lir�i�le t� retir� pricr to Jar�uar�;� 1, 2D13. C?�ti�� 2 belo�v rep��sents the �iardard or nQrm�l f�rrn af reti�ement bene�t fos participanis �ligik�le fo retiir� after Dec�r��k-�er 31, 2f712. �hE nth�r optic�nal fc�rms (#3- #�] shall �oe comp�ted tc be tl�e Actu�riaj ��uivaler�t of tl�� rUspe��tivz norm�l t�ene�it. Optian 1- Jaint a�d Survivar Anr�uitv #C]NLY 3f e6iqible to retire �r�ior �o Ja�uary '3 2U'� 3 ,�n �nnuity p�id snonthly fcr t�r� lif� of the Pa�ici�ant, ���ith a 1[}0°��� survivor annuity p�id mQnthEy �Qr a period af fiWe yE�rs fol!owing the death ai The Pa�ic��ant ta t�e bene3iciary; �arovi�ed thai falfawing s�c� fiv� ye�r p�rind ti�e sur,rivo� �nnuity shall �e r�duced t� �a°In �T Ehe original su;viv�r ann;,�iry �ma�.�nt. [S�e s�ction 2.397 t�} �3} (A}] The �a �icipan�'s sur��iving spou�a rG�CeiV�s the �1e51gna�ed a;r�oun= fo� the �est ��f hisJher life or unti� he!sh� remarries. !f n� s�rviving s�ouse: ci��erd�nt childr�n undcr ihe �ge ;�f 1� shasl 'oe ���m�� ta k�e ir,u �eneficiar;� a.�� rece�ve the desi�nate� amo�mt urstil the age of 1�. �Seczign 2.3�7 ja} (,3� �nd Sectiar� 2.3a� fb} (1j] tio� 2 — Life ,4nr��ai� �e F'art€C1�78fi�: fEG?I'�rLS }las?her pensian as lon� Gs helsi�e live,. llpon �he death of :he Pa���ci��nt, b�n�fits ceGse. F��.^..�ior. 2.�1 �('c;� ar1CI 5��tiGn 2.424 fb) (2} �. 1.] � a tiar� 3- i 0`�ea�` G�rt�ir� � L�fe l�nnui� - jrr�ust d�signa�� ��er�e�ieiarY) Tne P�rti�i�ar�r reGeives his,�he� p�nsior7 as long as he?she �ive•u. !f the Partiri�ant d€es b�f��e i2r� monthly pa�y�rner,s ��ve r�eri r,���ie, th� re�r��ini�� payr��r;:s up sc the 12a cayr��nCs �re mad� t� hislhe� ��ne�ici:�ry, or tc�� Psf�i� ii hisit��r r�En�ficiaiy is n�t�live. [5ec:ion �,G2� {�} ti2i �. 2.y � tion 4- 50"/o Jo�r�t &�tirviaor Ar�r�w� - 4mr!st d�sic�r��t� a�e��fici�rY'j Th� Pai�ivi��a;7t r��2i'G��s his�ner ��n�i�n as lonc� as he�s`�e li��res. If the Par?ici�ant dies �irst: the b�n�:fciar,� r�c�i�.�es 5�� per�.ent of the ��r�sir�,� �cr ih� r�wt �i t^� �er�e;iuk2f-;J's li;�. li the h�nefsciar�;�� dies firs=, :�e P�rtic;ipar�t m�y clect an�?hE� her�efici:�ry o� r,�ay continue to r�:c�i�r� 1GC1°.i�, o� n�7r'hE~• ��nsia�� anc� upon n°s!;�er de=ti�, �r r:eiits cp�sE. ��Prtio� 2.424 i b} (2'� a. 3.] Q �lOf3 � - ����a �Oiil� � �i]i�Jl'+l�f '�.�9E1�3�1V � �i7113�: G��[!�fi°d2� ?� ��i1°�IC9�t'1J� The Partics�ant re�?i���s his+`her pP�sian as I�n� as 'n�ish� li.+�s, li �he Part;cer��nt �iPs first, the benz�i:�?�rY� r�:;�ives ?� perv��t ��f th? �er�sicn �or ih� ;a�z cf �nu b=r�e�iJ��r~,�'s 'si`e. Ir �h� "�enefici�n� �i�s �irst, the °a;�i�ipdnt rr��y �le,�t �il��ih�l" �7pn��1C!�� �J� r71�k� GCfl�i,7sJ2 iD C�C21'u'� 1 �U'''�, Oi "1'�;`il'c'C j3�flS:�f1 �� i�i upon his!h�r �iEutr�, ��C1�TItS GE�aB. 1Secii?r� 2.?Z4 �41 i.?.1 �. �.� C1��#ion b-`IOt�`/� Jai�t c? 5�s�vivos �nnu;�u -{r�ust cJe�ic�nat� a b�r�eficiarYj The PS ��icf��:r- receive� hisi;^�er aensi��r� as Ir�n� a� �i�.sr�r I.�res. If the Pa�:ici�;:�nt ����:s first, :f�.� o�n�fi�iai f r�c�ives ;.?�) perc�nt cf :r�� pe`�sic�r� f�r �i�e rF�t �f rhe t;�^n��iici�ry's Isfe. lr tha �enef�ciary, dies fi��t, kn? P�rii�•i;��nt �7�y ele�i f �, r�r � ,,- r�r d��atr:, benEfi?s veGs�. ��r��t����� b�n�:,icia.� er m�y c�r�;inue t� recer�.�� i..�'��a of �is.�;�er pe��siQr� and ��.u"� h,�,h.. IS�cti�a�i �.42� ��} ;2) �. �.�: �ptic�n i— 6f �I3% Joint & 5ur�ovor Anriui� -�must desic�n�te a beneficia�"J'} 7'ne �'�rtp4i��r�: ��.ce�vES his,+':��r u4i°�si�r �s lana as h� 5h�v liv�s. li t}�:e P�rti�:i�ar�; dies fi�s�, the �ez�efsciary r��Eives �6 �ii a��-cent o� th� ���ns;nn �ar th�� rest ��f thG b�s�e'iciary's life. If th� ben�fir:iaiy di�s r�rst, t�� ��rticipa;�c n,�ay clwct �nothPr l�en�ficiary c�r may contin�� �c� rEC�i���� 1 ��°.�� of hsslf�er pe�sian a,�d �_,���n hisl'�er d�ath; ��r:vflts ��ase. [��ciic�n 2.4�4 f b',� �2j �. 3.] pariia�'Lump Stim Payment C}ption ,� p�rti�l lur�� sun� payment equal tc e;ther ter� pFrc�nt (, ,�'°.�p], �wrenty p�rc�?�t �2� ;•oj, �r thirt�,� ,r���eent (3��'ioj of Fhe aG.�arially �eten�i�Pd value o` th� na�m�l retirernent benefii du� �h��e r`ner���r may b�; el:=ct�d in c�mbinatson �,�riih a��y of th� c�pti�rs indic�ted a��ve. If a mer:��1�r elects s��c'•., a part�al lurr�� s�m aistribuii�n, tt��en th�� monthly retiremenk h�nefit f�:�r �he aption sel��ted shal! ue r=�duced acccrdf�?�ly �f�erea��r. [5�ction 2.�24 ;bj (�} a�.] I ha4�e consid�re� th� �ario>.�s �er�efit pa,�me�t rnet����s un;ier such Plan anr� ha}�� elected tc recei�� my retir��ne�t benefits as indicated below. (EJate: �p�:ior, sel�cti�n to b�: i��dica#ed both by Number and DeSCriotion.) !�:nc:��rstanei ��'9�t ^,�'�'.G° TTl`V flfS': �."',C'ncinn rhark ig t��CRVyPri� iil� �ECISI[71l tSTI 1�}1[5 4�?�i[Jf1 iS II'i2'dDCaI3��. if taking �pts� �ptian #: _1 il "1 S1�T7 �]2�i]W: Employee's Si�natu�e: �]escription: J�int and Survivor Annui CJ�ie: � C7ep�r:�ent �hildren ���d�r the age �f 1�3 ana residi«� ;r� rr,y I�ousehold are: ' Chil�'s i��me Gend�r Date o� Birkl� if �akin� Option 2 sign ��Eow: _ _, _ � C�ption #: 2 Dzscripci���: Lif� Annus �rrip'o'�ep's Sigratu:e: -- — -- _ Da#e: _ - � �akin C]ption 3, �ill in �Oeneficiary infiorrriati�� ar�d sign b�iow: _ I U�tio� #: __3 i�es��ri�ti��: �� 'Y�ar C�rtain and L�fe Annui;y� f�rly �esi�:��te� ber;erici�ry� is: ,_ �-_.��� ',; �1 ���. , i r'" Social S�cur{fy �lum�ber: �l�,me � �� � ; v- �, ��.� ��_ ��`e �i Birth: E ` s � # ��1 � ��� Gende� [Circle C]n�} (�fv�� � f'�C�CiS��^S�. _�� �L-% �� I [�i' k.C='- i':.°a 5r- �','s�_, � ��a _[,.�_ r ) �,..7•_l �.— h (t- ["i= �- --� € - � � t � Nh�re Uum��r: t ' �• �_' _ 7 �i71WlG�V'?US �I�(18iUf?' ,f'� ` � � _ ?� r � '� `?� � :} �;, ��iP" j .f- ,�'- :,` li [d�ii-tt ��uitr'. . ,- ,- __ � �:�: :.. r-.��:�._ �i...,,s, r -I�„�..,.;.,;-:n>, _. � h„r�.s;,.�-.n. � ' �„a4-nzi :a�,.r� � , �,v?�."1' —— � j �}.. �j. S�.:li f � kF3i fll VI.J{IVf! lYiie]IIJ'�G}� �!C'—JLI IrJLiJ11 Pi�4a �,..r�- �. n��+ :.ii�'l.'n....---1.1-- -=':�.- - - .-__ . �-.� .._ _... . _ - . _ _ -_. rJ�!t�c�n �: - -- �escr��ti�n: _ ''�� Jair�t �r��%Survi�ror Finr�iir� _ fvlt,� desi��n�ked f�?ne`ici�ry is: �lam�:: C'r`at� Cii C51i �Y1: �l.[� (� ri? S S= Phor�e Pdu�r���r: Em�ioy�?'s �ignat�r�: �� _ – �oci�! �ec�lri�,�,� Nun}Lvr. Ge��ivr (C�,��,I�v �n�� Nl F CJ�t�: If �aking a Par�ial Lump Sum �ayment, fill in Percent�ge �nd sigr� k�eiow: C7�tic�ri �: h�A ��rcription: J Par�i�f L�.i�r�p S�_im Paym.ent _^_ I elect ta t�ke ��arfial kur��� sum payrrent ir� :he �u;iu'winc� �r'�n;�r,; �chec� onl}r c�n�f: � 10°i'o of the act�ar;ally cietermined va;'�e af the norm�; retirer�ent k�enefit 2�°fa o, ih!: actu�ria`fy determined r.+�lu� of t�e r:orrnal retirernenf be�efit 3G'%� of thv actu��ially Jetermined �al��e of �h� norsnal r�iiremerit �aen�fit I� I�.�n�ers�a��d my monthly retirem�nt ben�fit for th� apti.an s�lecte� abc�r� shall be raduced accordingly. �' Employee's Signature: ,f �� �. ��r� � Date: _ r _ – ` .. - � r - .�-- - ...._ r If r�aming a b�n�ficiary ��L`l, fil! in beneficiary ir�forrnatiora an�i �ign t�e6ow: ; N�ly �ESic�naced benefician,� is: Bz�ef4ci�ry �]arne: Berefieiar,+ Dat� of Birth: ��r�e�iciary Acfcress: Ber�efci�ry Phone lVumb�r: �rnpl�y��'s Si�nature: — � � #� �.� i- (�F FL�.JRf�7i`'�, CC�UrW��'( GF r-;����_�s �e�i. ��'�l i� � �rm �G9[7C]-����J9 Beneficiarr,� Saci�l Security #; �en�ficiary �?nder �Circle �nej M F Dat¢: I I-�� fare�osn� ir�5k:`ur:.�a;;t �,�d2s a�:kn;!�;�I�d.�e_1 t�efore me this � _,, =�: f ��, , '�:�i- � da � of r,� -! , �C��•'-� `[� , r t f _._ — �p, _ �,,�r�,, �'-,��f-� • `. �^, , -, - . �v��c is personallv kna�r�n to n�e ��UVht� h�s p��vide�� __ �s scen��i��tion �nd vy?ho di;�ldi� �ct take ar� c:�i.r . `_�) _ �"� � j.:�6%-"-�_ —'A !l 4"w-r ,�-�{'-�4..�.. _. --- I� -- rS'ien�[ur°1 �. � ..r,�' l.'��. ���f�/':--E �-- �� i�4+ly Comn�issi�n ex��r�s L1�,� Y. �:.�3��Ri�� �'F,�.�?`! i�U�l.4� � �TP;a � <?s= �1.�3R!$�,� p ��rs6riid� ���20i75 � �4�e� "T��#��1 Fi ,'�7.�rf�'-= �'�`�iary Puaiic �l�r„� �; Na3�n1 Printe�� cltE I\�df`Pc �a�SlJfi +-f1L'7L��ffS�^-flL �i�iID�Y rOflTl � 1-n .]ISu.�.,. " p.��cir�,r. - ; FS . — ' ' --..._- r`' , -- -�.."-.=•�=�-y���- Sec�ior� Ill. I3esignatian of F'ersor�al Repr�sen�akive i h'�e Ciiy ne�ris t� �e nuii;��ci :r :he evei�:t �f y�ur �e�t��. 'Ycu nee��i to �'esi�•ia?e � f��iiy or ��ersary��l f�}�i�jEfl'Gii!�� :� hanti�E Ii'lIS rESPr7pRS;i�l�l�j`. ��.lyi :�'i� i'7�f?l�' of'he �7�i5C'.1 'VGL' CX�i�;� f l� �C7 �ill5. Th`� IS not a b�n�ing �°iisior� �n�: an_r+ �ther p�rson�l repre�er':�t;v� may ati�nti E� khs� respnr,sibi4ity,� The far��il�� or pErsonal r�pr�se;�tative Gti�h�� wi'sl ad��i�e t��E City or C?��rv���a�er, s�� G^.�ri:inq, LJt70fl fT1V ��ath 3s: Narr��: -'� �=rr��, �_.i_ �F-__ �;_��� c��i s�_ --- - --_ - � � 1 �� ��i�� i ���f�T� r E- � �� �'.cl�res�: _ ._ _ _ _ /��,�?�=`f'' �jr-'�'+°~1!i F _�. �? ������t.� --- Phon� �Jumb�r: Rr�a Ga�� ��{' Numt�er � �G :� �j �, _ ._ _... _ ���-�� � _ C�RTiFIGATI�hI ] nereby certs�y� ihat all #he pr��Eding infermation in ���r� secticn is true and c�rr��nt, and 1 ack;��v�+le��� that any faksiftcation �f the �areceding informakian ��ufd be cr�nsider�d rr���dueent �nd couid r�su�t in my p�nsi�n ben�iits �eing �,vithhe€d. ''..��•`-:`"�--�ti{ ' � ;� �-''',. - I Si�r�ature of Pers�r� R�ceiving F�e�isiar� Pa+�er of Attorn�y 61f �aw�r af Attc�rney is n�c�s��ry, attaGh a copY-} STAT� C�F FL.C�RfaA Tt�e faree�oi�� instrume��i w�s ac€cnowl�dged ��fore sne this "?,' $_�"T u�_:, ioa �rr CJ�JN � Y G?F I�INELL�.S b�, ''--,k-��,�.�,rvr c��� �-'��� :'� wha is r��rsnn�lly kno��n to r'r�� �r wn� nas prg�t�ed � _� as ider�iizic�tian (D � � � and'�hn,didlJid no� t�4���z�-,oath_ , � ��,: � _��-�� ; C.;.,—t� �. _ �: f�i.�;laiLJfE} �r . jI'"� �..�'.',�` �.;l������? L.� ] - �,:� Cc�i�n°�i�s��:� f�l�.. ' - .-�! ''_--_ � K, � q�pTleP[Y PI]�-� �i�.T� c�� ��.C3Ri� , Crrrr�rr►#�fi �'�2��� �xP�s�s 7l29i���IC Noiary P�blic �f fJa�ne of Natary Printed} Rev:s�tl 12'�3 -�L; ":am•�: .'v�nu21 G�'_ nf Pension -n:it,e �nrm'.^^S^��W�,4=�� 1lernher I}ata Narr� e ❑atc �F Bi�t]1 Age at 1�.etirea�r7ent 13eneficiary Data 'V a��1c L7alc �f F3irth A,�z ai Retire,ncnt Retirement D�ta Hire Batc '1°ern�inacsc�n Batc �ffe�:tive Date 1�:�C Cpntri buti ons I��t�i�est Cit�� af' �'le�r����i�r �:r,�pl�ayr�C�f R�ti�-�m�r�t S�rst�rr� Senef�t Estirnat� s�rE�x��iE 5�r���r��,�,�,Y U313[111��� 58 Vears 4 i�'Tonths 2 Tlays DAIVIEL 57'�FANF.I.i.T r1�a1ri�79 33 Years 9 14'fo��ths 1 T1] 6(1992 Ut3101,12U13 oxaui�2ai3 � 4�,5�2.29 g �.[}{} � U.O��D Soci�sl 5ecuritr� Na. 5o�ia1 Securitv No. Relationship : Chitd # of chilcfrcn under 18 : [1 Ca?culatinrr Typ� Estirnate B�nefit Grau� � ; I�c�n-TTezsrdous - Grandfathered ki:tirci�iciit °f'�'p�- _;, : Normal Re1iz`ertaent C?ption �le�:��d � : Telor�nal Forrn Parl.i�:1 I„u�p'''��t : �29,35�.9� (1D %) t aCa.Ll�,_I��'r�er Ser�,•ice : 20 Y�ars $14'�anths lS I]ays ■ ;. � Forinula for ]3enz�t A : Z.75°,'0 �` 2D.7fi43 _y�ears ` $45,"s�}y.2_9' ',�:' n laarrn vf Pavment =. ��,� 'Factor Sinblc Life ,qni�u�ty ��' 1.f�00C}f} i f] Y'eai� C�zt�in as7d Lifu /�nnuity �° L�.'��015 S()��" Jainl arxd Suiti•i��nr =°��� �� _ " (].2�II9? 75°1.4, Jaint �rbd Suivi��or � f].23462E� 100° i� .�c�int �nd Surviv�r �� >"��� �.f��}�Ul �, '� �'� � (D � � � Pv'Ion#hly iicne�t �'otenfidl 7'a 11��ember TV t3ene�icaary `� 1,947.29 NIA � 1,94�.f�9 Nl.q $1,7:�fi.93 �S$Ci8.46 $],f�7.91 �1 �3�,93 $1,5�i7.5� $i,��7.5R - i�1C 1�SlIITS �{lS��.L.i_•:��i� ..�-� Ti;l� I�Ii1�1.f�iilb:;:` �71t[�7C�:cti f:iFil1' ❑11(1 LoR���tiS CC}lylll:lll] 4:aI:�C� L'.[il:l�+:i5i;' S�l(+U€L� I1EYi flc. T�i.dlcC� .I: rli��11 ;�SLi�TS. �'his cal�t�laii�n is suh.ject to ���zrection. It y'�u aE•e nr heco�j�e a���ai-e o# eizars in tile r�a€a ihat �sa5 ttsecl, the calculatintis that ti��eYe made, er the ptan pro�: isiE�i�:, that ��•ere ap��li�rl, ii ic your �•espos�si}�i13ty ta ce�ntact the pl�n adi�zii�istxatoY. The }?ian 1�a, the rigl7t [o recr�ver fron� youLd aiv?ounts that wLre �aid f� vo�i in en•or. xxis�;�cr.�F:cA'r.1;k�Y�':�•Y,'r,::r.:cx::::;�Fx'�'�-�.95 6.'9 �}H1Nj�' ��ii �5�1�1'9�'��'�ts�t�rr.-';�:�xr �x�::?��:•r.-r.x�x�r:�x�s:�: �iE? S Bc��cf�4 Calcu3;�tcn (L'_�_1?S'} - f.U.4;�i.19�Gfi { Pi�CYQ) IDr ]75 5;`22;'Zi113 { 0:i9 �8 ANt