08/12/20131. Call to Order
2. Approval of Minutes
PENSION TRUSTEES AGENDA
Location: Council Chambers - City Hall
Date: 8/12/2013- 1:00 PM
2.1 Approve the minutes of the July 15, 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 request of the new hires for acceptance into the pension plan as listed.
� Attachments
4.2 Approve the request of the following request of employees Kathleen Bedini, Engineering Department;
James Beardsley, Parks and Recreation Department; Thomas Milne, Police Department and Richard
Crean, Police Department for a regular pension as provided by Sections 2.416 and 2.424 of the
Employees' Pension Plan.
� Attachments
4.3 Approve the request of employee James Geary of the Customer Service Department to vest his pension as
provided by Section 2.4] 9 of the Employees' Pension Plan.
� Attachments
5. Other Business
6. Adjourn
Pension Trustees Agenda
Council Chambers — City Hall
SUBJECT / RECOMMENDATION:
Meeting Date:8/12/2013
Approve the minutes of the July 15, 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
C�' ,';.L;I �1 : fl �fm � f $�' �II� 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 S. Silverboard - Assistant City
Manager, Rod Irwin - Assistant City Manager, Pamela K. Akin - City
Attorney, Rosemarie Call - City Clerk, and Nicole Sprague - Official
Records and Legislative Services Coordinator.
To provide continuity for research, items are listed 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 2:05 p.m. at City Hall.
2. Approval of Minutes
2.1 Approve the minutes of the June 18, 2013 Pension Trustees meetinq as
submitted in written summation by the City Clerk.
Trustee Bill Jonson moved to approve the minutes of the June 18, 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
Approve the new hires for acceptance into the Pension Plan as listed.
Pension Name, Job. Class, & Dept./Div.
Date Elig. Date
Kristina Cook, Accounting Clerk, Finance Dept
Peter Chaplinsky, PS Tech I, Parks and Rec Dept
Hire
05/06/2013 05/06/2013
05/06/2013 05/06/2013
Pension Trustees 2013-07-15 1
Item # 1
�
TaSheena Spearman, Eng Spec I,Eng/Stormwater Dept 5/13/2013
Andrew Hayslip, Planner II, Planning and Dev. Dept 05/18/2013
Randy O'Kelley, Bldg Const Ins,Planning and Dev Dept 05/20/2013
James Benwell, Drafting and Mapping Tech. Eng Dept 05/20/2013
Attachment number 1 \nPage 2
05/13/2013
05/18/2013
05/20/2013
05/20/2013
Trustee Doreen Hock-DiPolito moved to approve the new hires for acceptance into the
Pension Plan as listed. The motion was duly seconded and carried unanimously.
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.
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 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 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 (65)
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. Ms. Ready met the
non-hazardous duty criteria.
Trustee Jay Polglaze moved to 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. The motion was duly seconded and carried unanimously.
4.3 Approve the request of the following employees Mark Sena, Police Department;
Pension Trustees 2013-07-15 2
Item # 1
Attachment number 1 \nPage 3
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.
Mark Sena, Police Officer, Police Department, was employed by the City on
August 15, 1988 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 $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 Department, 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 effective June 1, 2013. Based on an
average salary of approximately $75,519.59 per year over the past five years, the
formula for computing regular pensions and Mr. Nuebel's selection of the Joint
and Survivor Annuity, this pension will approximate $53,160.00 annually.
Stephanie Stefanelli, Parking Manager, Engineering Department, was employed
by the City 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
for computing regular pensions and Ms. Stefanelli's selection of the 10 Year
Certain and Life Annuity, this pension will approximate $22,903.68 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 (65)
Pension Trustees 2013-07-15 3
Item # 1
�
Attachment number 1 \nPage 4
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. 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 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. Sena meets the hazardous duty
criteria.
Trustee Bill Jonson moved to approve the request of 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. The motion was duly
seconded and carried unanimously.
5.
6.
Other Business - None.
Adiourn
The meeting adjourned at 2:06 p.m.
�� �, ��
Attest
City Clerk
Pension Trustees 2013-07-15
�
Chair
Employees' Pension Plan Trustees
4
Item # 1
�
Pension Trustees Agenda
Council Chambers — City Hall
SUBJECT / RECOMMENDATION:
Approve the request of tbe new hires for acceptance into the pension plan as ]isted.
SUMMARY:
Name, Job. Class, & Dept./Div. Hire Date
Jorge Hernandez, Gas Program Specialist, Gas Dept 06/03/2013
Andre Dodson, Solid Waste Worker, Solid Waste Dept 06/03/2013
Joel Rudolph, Field Service Rep, Cust Service Dept 06/10/2013
Dustin Dulek, Parks Service Tech I, Parks and Rec Dept 06/17/2013
Louis Christou, Accounting Tech, Parks and Rec Dept 06/17/2013
James Cooney, Utilities Mechanic, Public Utilities Dept 06/17/2013
Kris Koch, Recreation Supervisor, Parlcs and Rec Dept 06/17/2013
Jeffrey Gavani, Per/Payroll Tech, Parks and Rec Dept 06/17/2013
Zachary Gutshall, Park Serv Tech I, Parks and Rec Dept 06/17/2013
Marlon McIntyre, SW Worker, Solid Waste Dept 06/17/2013
Review Approval:
Pension
Elig. Date
06/03/2013
06/03/2013
06/ 10/2013
06/17/2013
06/17/2013
06/17/2013
06/ 17/2013
06/17/2013
06/17/2013
06/ 17/2013
Meeting Date:8/12/2013
Cover Memo
Item # 2
Pension Trustees Agenda
Council Chambers — City Hall
Meeting Date:8/12/2013
SUBJECT / RECOMMENDATION:
Approve the request of the following request of employees Kathleen Bedini, Engineering Department; James Beardsley, Parks and
Recreation Department Thomas Milne, Police Department and Richard Crean, Police Department for a regular pension as provided by
Sections 2.416 and 2.424 of the Employees' Pension Plan.
SUMMARY:
Kathleen Bedini, Staff Assistant, Engineering Department, was employed by the City on January 5, 1998 and her pension service
credit is effective on that date. Her pension will be effective September l, 2013.
Based on an average salary of approximately $30,717.58 over the past five years, the formula for computing regular pensions and Ms.
Bedini's selection of the Single Life Annuity, this pension benefit will be approximately $13,208.28 annually.
James Beardsley, Parks Service Technician III, Parks and Recreation Department, was employed by the Ciry on November 12,
1974 and his pension service credit is effective on that date. His pension will be effective on September 1, 2013.
Based on an average salary of approximately $42,182.56 over the past five years, the formula for computing regular pensions and Mr.
Beardsley's selection of the 50% Joint and Survivor Annuity, this pension benefit will be approximately $47,207.16 annually.
Thomas Milne, 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 l, 2013.
Based on an average salary of approximately $83,016.18 over the past five years, the formula for computing regular pensions and Mr.
Milne's selection of the 100% Joint and Survivor Annuiry, this pension benefit will be approximately $43,813.44 annually.
Richard Crean, Police Sergeant, Police Department, was employed by the City on December 30, 1991 and his pension service credit
is effective on that date. His pension will be effective August 1, 2013.
Based on an average salary of approximately $91,966.96 over the past five years, the formula for computing regular pensions and Mr.
Crean's selection of the Joint and Survivor Annuity, this pension benefit will be approximately $54,742.56 annually.
Section 2.416 provides for normal retirement eligibility for non—hazardous duty employees hired priarto 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 twenry (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 reached 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. Bedini and Mr. Beardsley have inet the non—hazardous duty criteria.
Section 2.416 provides far normal retirement eligibility for hazardous duty employees, a member shall be eligible far retireinent
following the earlier of the date on which the participant 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. Milne and Mr.
Crean meet the hazardous duty criteria.
Review Approval:
Cover Memo
Item # 3
CiTi `t° �� G�.ci�t�vv�TE�'s
EMPLC�Y�ES' �EPARATIUN PAY PREFER��]CE5
�:����
� � �- ;� � � �.� ;r. ;� 1 c�
�
'�REFERENCE #'t Emplc�y��s c�n receiVe � 13fmp sum payr��er�# for vacation, flo�ting €�r�liday pay: sici�
leav� incentiv�, bpnus days (if applicable}, and 1I2 af accru�d sick le�ve ai the tirne
of separa�ian frorn the City. There will k�e na deciuction tor per�sion fr�rr� �his I��r��p
sum pa�ymer�t nc�r will this �maun� c��nt as e�rnings in the caicul�tjon of the
pension. The last �ay of work vtrill be �he terr�inaiion date and pension ber�efits +r�ill
begin th� fc�IloWV3ng r�on�h.
�REFERENCE #Z Emplr�y�e can e�end t�rminatian date by p�r� or �I! of the time due fc�r vacatian,
flaating holiday pay, s€ck leave in�entive, �oa�us c�ays (if applicable}, an� 11� of
accrue� sicls leave_ Empioyee may c�toose #o run c�ut this t�me in any manner.
Balance wil4 k�e paid in a lump sum on employe�'s final p�ych�ck. Terrnir�ation d�te
wil� bA ti��e final day af extendea time. Pensian €�enefits vviBl �ec�in the fQll�wing
mor�th.
l ��;i�'�� fv �����r�:!. . an �mploy�� of the CRty c�f Clearwater, hereby �pply for ��r�si�n
benef�ts under ti�e City's Employees' P�nsi�n Plan.
I here#�y ce�tify t�at 1 fuily unde�stand t�ie prefer�nces Offered t� me. 1 choase ta retir� using separ�ii�n pay
pr�fer�nce # � and wish rr'�y b�nefits to be calculatec� under #�is g�reference_ F'I�ase use my le��ve in th�
fQllowing manrrer:
Run Uut
Lump S�m
vacatGOn
�'`�� } vacatian
si�k floater�
bonus haurs
_�1�• C` sick ��_': �_� � float�rs bonus haurs
I unc�rstand tnat my preferenc� �ann�f be ct�ar�ged on�� this farm is signed and that my dec�sian is
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irrev�cable. ,� ,�-` t ,
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1ttii5 calc.ul�tiQn is st�}�ject to carre�tian. Ify�+u are c�r hec�+nae av��ti�-� of cn��rs in tt�e data tk�at Gz�s use�l� tt�e �alctilations t17at w�ere
maci�, c�r the p[an �3rovisrons #haE t��er� a�+�lied, it is }`�tzr respa�nsil?ility #o cantact ti3e plaa7 ad�i�i��istrator. �'lae �laa1 hati the right to
recover #rom y��� arnou�sts ihai ti3�ere paicl t� yc�u iil crrc�r.
$r:::'8:9:1�*��3c�;:�r:�z:'�9:'nA'�.:':�i;i:vr7r AAi�u �� �?���� i�.71 ���1�$��� �''"c��ty%�':•'r.�;f-;c•nx•Y.:�:�:�a���',r�k9;�'c:'::c�:�9:
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CI�Y' C3F CLE%eRL�IA i �rc
�ENSION ENTITLEMEIVT OPi14N ��QUE�T FC?RM
i�OPd-i�AZARDOUS DUTY EdVIPLOYEE
_. . . T- , F . '`~��� _ . , - - ' Y � f� Y -
� ��;.��.-,�, �� �o hereb � I To s�c�sve benefits under the
City �f Cl�anrdater Gen�ral Emp9ayees' Pension F'lan in �ccor�iance v��ith the fallo`aving
�',��'� �I�j� � Gender circle one M �F �
i Date af '�irth: / l� ( }:
' J�� Classific�'ti�an: .�`±r-��? �`-��a�:.5-f-'�--f= __- .
aEpari��nent �`�r,��n�r'F�r,�c� �]i�rsicn: I;,� r�!Cnc:1�1_
Dat.e of Hire __ �,,�' : ��, ,_ --___ . []a�e of Se��rat�an: �/,�.;3 ,�r �.
[?enefits E�re4,tiv��at�: "�;', ;� :r�: � _
Spaus�'s i�ame� _
Spouse's �Jate of Biirth:
5pouse's Genr��r �circle ane}
The type of per�sian tor ��.vhicn I arr apgalying is �ch�ck only c�ne}:
}� Re�uia� P�nsion based on y�ars o€ servi�e
,Jot�-connected Dis-ability P�nsicn
�'� Nan-jc�-connected E�isability I�ension
M F
The City of Clearwater Ernployees' Pension Plan provides rnultipl� optians to Plan Pa�ticipants as ia the manner of
kh2 pension ben�fit pa�J��nt. C]p�ion 1 bel�w re�res�nts th� skandard or narmal farm of retirernAnt ben�fik for
Participants Eligible to retire prir�r to Janu�ry 1, 2G13. C��tion 2 belflw represents the standart€ ar nc�r�nal for�r� af
retirement benefit f�r F�rti�ipa��ts e€i�ible tQ retire af�er �J���mber 31, 2412. The oih�r oatian�l fr�rrns �#3- �7) shaCl
�e computed to 6e ihe Actuarial E�uiva�ent af the respective norm�l benefit.
Q�tion 1-.�oint ancf Sur�i�or �nrruity ((�hJ�Y pf �efiqible to retir�e g�rior to Jae�uary 1, 2U73j
An anrs��ity paid �n��thly �or the fi�F� cf the Participant, with a 1{1C1"f: surv�EVOr �nr�uity paid mor�thiy for a period of #il+�
years fol6nwin� the death of ,he k�artivip�nt to Fh� b�n�frciary, �rQVided tk�at following such five year period ihe survsva�
an�uity shall he reduced t� 5n°{� �� the arigina4 sur��ivar annuity amau�t. [See section 2.3�7 jaj (3} [A}] The
Particip�nt's su�vivir�g spo��sE recei�es the d�signated �rno�snt far th� rest of hislher lif� or until h�lsh� remarries. If
no surv��ing spause, cieoendenti childr�n under the age Qf 18 sf�all b� deem�c� to be the beneficiary and receiv� the
d�sig��t�d amount untEi the age crf 18. [5ection 2.397 (a} �3J a?�d 5�ctiar� 2.3a8 {i�} (�}�
$Ian 2 — LI'�E +�flilGl
�he Partici�ant receiv�s ?�xslher p�nsipn as lang as }�eJshe fives. �Jpon i�� death o# the Participant, b�nefits cease.
�ection 2.4� 6�cj and Se�tion 2.424 (b) �2} a. 1.�
t�
�p�ior� 3-'i� Year Ce�tair� 8� Life �+nr�uity -�rnu�t d�sog��tE � t�eneficia�Y)
The Participant rece€r,�es hislher pensic�n as long as he!she IiL��s. If the Participant di�s ��fa�e 12D mor�thly ����rnen'ts
€��ve bee� made, t�e �em�ininy paym�nts up to t�e 12�J �:ayments are ��ade ta hESlher benQfi�iary, or the �state if
hlslher beneficiary is na� alive. f��ction 2.42A �b} {2} a. 2.]
O tian �- 5U°la Jvir�� & Survivor :4pinui -�m�asi de�ignate a taene�ficiary}
l�h� Par[ici��nt receiv�s :hssif�.er �Ensior� as fpnq as he,�sd�e 1iv�s. ff i1�e Partic�pant di�s first, thP henef�ciary rec�ives
;� pIIrcent af �he pensior� f�r [he r�st caf the bersefici�ry�'s lif�. IF �h� a�nefscian� �ies �irst; :he Partici�ant n-�ay elect
anather ��n�ficiary or may �.�ntinue ta rec�i�d� 1a�°lo �f his�her pension and �pan hislher d�aih, bcnefits c?ase.
{Section 2.42� {�i {2} a. 3.]
Op�io� � - 7�°/a Sc��s��_� �urvi�e�r ��r��i - ���st d�s�gnaie a ���t�fi�iarYi
The Particinant reccives �is�`h�r ��nsion as long �s he�sh� IivES. If khe Partici�an� dies �°sk: t �e b�:�cfi�ia.ry r�cFiv�s
'S per�en� �T ihe p�r�si�n f��r tr•e r�sk a' ihe �:er��iiciar�'s life ifi knc k�er �e�iciary dies ff� st, tr« ��rticip�; �t m�y �I�ct
anaiher �er�efic��ry �r may c��tinu� ka receiv� 'IOC��ro �r` rislner p�nsian ar�d uoc�n hislher �a�ath, 1�ereEits caase.
[Sec�ior� 2.424 t;b� (21 a. 3.]
�] tiflr� 6-�04°I� Joir�t &� 5urviVOr Annui -[must dssignate a b�:neficiaryy
The Part�cip��t rIIcei.�es hislher pension as Iang as l7efshe lives. if th� P�rtici�ant di�s first, the benefician,^ �eceiG�es
1DD p�rcent ��i the �ension ;or the rest of th� �en�ficiarys IisE. I� th� ber��f'sciary �ies fi:st, the P.��tici��r�t ���y el�Ut
�nather b�nefit:iary or r;�ay cantinue io rec�ivc �C�C]°Io af his'her pes�si�n ar�d up�n hislher ��eath, bGn�;its cease.
[S�•�:ion 2.�24 (b) l2} a. 3.]
C}ption 7— 6G zl3°lo Jaint & Surv�varAnnuity -�rnus# desig�nate a f�eneficiary}
k h� Pastic;pant receives his,+her pensiors as I��ng �s helshe Cives. Ir ih� Participar�i di�s first, the �Ene�iciary rec�ives
5G "! p�r�ent af tr,e p�nsion far the r�st oi ihe beneficlary's life. if the nenefici�ry dies first, the P�ricipant may ei�ck
anather benef'sciary or may continue ta rECeive ±00�/� af hisJher pension an�� upon his�'her deaYh, be�ef�s c��se.
[S�ckiun �.4?4 ;b} j2) �. 3.]
Partial Lus�p Sum Payme_nt C7ptic�r�
A�arti�'s lurnp sum p�yment ��u�� to �ither ten perce3�t �1�°I�}, twenty perc�nt (20GI�}, �r thi�-ty percent (3L�°Ioj of th�
act���riasly determined value of the narmal retirement benEf4t du� the member rnay be eiecte� in �ambkn�tion v�rith any
Gf the c�ptians in�icat�� ab�i��. f� � mem�er �le��s auch a�a�:ial lump surn distri��t€on, then the monthly retireme�t
bereft for th� aptEOr, select�d shall be r�d�iced a�,cardingly iherea�er. ISectian 2.424 (b} {2} a. 4.g
I h�ve ca�sidered ti�e various benefit paym��t rr�ethads unc�er s��ch I fan ar�d have elected �o receiwe rrsy retirernent
benefits as indicate� belaw. {1�Qte; Option s�leetion to be �ndi�ated both by Number and aescriptian.)
9 understa�ci tha� ance r�ry+ �irsi pensic�n �t�se�9c Rs received, r�ry de�isi�n ar� �his o�tao�r ia irrevoc�ksl�.
If takirag C]ption � s�gn qeivw: -- --
O�tior� #: _ 1 Descri�tion� , Jaint �nd Survivc�r Rr�nuity __
Err�ploy�E's 5ignature:
Date:
Qe�endent chi{dren under the age of 18 and r�siding ir-s r-ny househ�nid �re:
Child's fJame Gender C3ate of B9rth
If ta�Cira Optian 2 si n belc�w: _
� p��in� �: � Desuription: l�afe Anc�uity
i '
�
�' � #? �� � ' � �� � �=�
�ployee's Signat�ire� _
�
l�aking Option 3, fill ar� berseficiary in�orr�a�ian and sign belc�w: _
I��;q� # 3 []escrip�ic�n: 10 Y�ar Certain and Life Ani�uity __
iJate:
My designa�ed ben�ficiary is:
�J�m�:
❑�ie oi [3irth:
Address:
Fi�or�e Numb�r:
Socsal Security �lum�er: �
G�nnder ��irc[e Dn�j 1VI F
Em�ioyee's 5ignatur�: ��t�
��[ r.�[.°.,.. r"���IQiI �, ��••> 7 f�l! CR ��tQ'�°! �l�f??h�r f3sscrrir�tann aC'!C� k3E.'?1€.'$9GFc3 I!i{DC?7"�a�iCaP3 ��9� �3�37 �S2�ClW_
e� tisani�i+�. r �"—. .:�._ . �"_ � _. . �—
Qptian #: _ E�escripti+�r!: --- °/� Jcint ar�d Surr�i��ror Annuit��! ._
M�r designa`e� bereficiary is:
h1� 11"12:
�3dte of 8ir�h
.}^,ddr�ss
f'hane �]umber:
G€�i�,loy��'� 5't�r�a`ur�:
5a�ial 5ecurih� Nu;nber: _ __
Gender j�ircle C7n�j 1�+1 F
��t�:
If taking a Parti�l Lump Sum Payment, �if{ in Percenta�e ancf sign beeow:
flption #: NA aescri�tion: � P�rtiaf Lump 5um Pay_m�nt
I esec� �� td�e ����tial I��mp sum Nayrnent in t'�e folla�virg �maurf (check onl, or�ej:
'40°/� �f the �c�udr�ally determrned valu� of th� nprrn�l retirement b�r��fit
2�J°Io Qf the actuarialfy determined �ralue o� the n�rmal retirerr�ee�t benefiit
3�°I� of th� a�.�ariaily detErrr,ined v�iu� of the norm�l retirement benefst
1 underst�nd m!� rnonthfy reti�ement ben�fit'for the optiQn se�ectec4 aba�e shail be reduced aacr�rdingly
�rnplayee's Signa#ur�:
[?ate:
�f narrbir�g � ben�fc'tary �1V�Y, fill in ben�fi�i�ry infi�armatior� ��d sign belo�:
�-.
i My desi�nat�d beneficia�y is:
I Beneficiary Name:
l
� Bene�iciary i�a�e af �i��h: _
Seneiiciary Rddr�s�: _
Benefl�i�ry Phane Nurr�k�er:
I�pic�yee's Signa#ure: _.-
L�
�
`F7-
c.�-(A f E �F F�{}F�IQf�
�CJUNTY DF'
�'f f� ELLAS
_ Beneficfary Sacial Security #:
B�rs�ficiary Gender tGircle One} M F
❑�t�:
I he for�gcing +nstrusr�eni was �cknov�f1�lged ��fQre me this
'` ��,,� /'i =3�
'�' � d�y oi `�-- :��. ��>_ ��f�=
by —, ' � :;:_f '''� r
wha is p�rsonal
kno�rrn. to rne or �vho �as prousded
� r".- -
i�n and v,��h,o di�ldid nai tak� a� oath.
� j 'i _
� � i ��. :.� �`� fl�„� r���r _ .
�v1y Comrnission ex�ires: � (
f�ciary Public
fJama c�f N�tary P�fnted
�ev. 04i13 �t�e K. [�C��!%i�
'=orm �9�C��-.C�G����J - �'°°�� �t��4'� �ife �iame: FensiGn EntEklerrier!t C7��son For�r�
�,A'�'� CiF �LURIEB�C
• 9 0 �`�s�s# �E�i25
-� ��� '�#��1�'01 �
�..i B 7 vi t��i��liCV+iH i CC5
���IPL�YEES' SEPARATGQI�1 PA"Y PR���R�hiCES
�- r�� �
.�� �-�,+i [ � '��'7`{
�. �� � �� �
P�E�ER�hJCE �1 Er;��luy�es c�r� rec��i��� � lurnp su�r� �ayr��art fcr vac;�ki��r, fl���tin� hc�;ida!,� ;�ay, si�ck
lea���c i��centiu�; k���us d�y�s {if ap�[icak�Ez}; ai�d 112 nf �rcru�d siLk ;ea�r� at the time
�i sep�r�ticn frQrn the City. 7he;-e �,��il! be r�� d���.cti�� fcr ���sic�n frGrr� t��;s lur�p
s�am p�r';r�ent nor wi!I t�sis an�aunt cc�unt �s earnings in th� calc�_ilafi�n ai thF
p�nse��. Tf�� I.ast day of uvor� y�r�ill `�e th� t�rminatian �i�aie �3�� p��sion b�nefifs �v;l;
b�gin the f�ll��r�fin� manth.
PR'�FERENC� #2 E���loy�e can extend t�rn�inatic�r� c#ate ��� part �r �3E of the tir7�e du� for ��cati�n,
fioatin� halirlay pay, s€ck leave incentive, ��nus d�ys (if ��plicabl�i, and 11� of
accru�d sick leave. Err�pEoyee may c}�r�ose i� run o�it this tin�e in any manner.
Balan�� will kae paici in a lump s�rm on employ�ee's firia[ �ay�chLck. ��rrr�ination clat�
��ti�il! ue the ��nal �ay cs �x�en�pc� tir�e. �ensinr� be� ��,`;�s wil� ��gi� tF�,� ��llc�vinc�
rmont�.
-� --
�r~
I, ,�., �_� ,;'� f�`7��'`, , an empl�yee �f th� City of C�earwa�er, hpE-eby ��p�y f�r pensian
ben�fit5 un�er the City's E�r���lo�' �s' Pensicn Plan.
1 h�r�by ee�tify that i�ully us��i�r5i�nd th� prefer�r�ces offerec� ta me. f c�oc�se ta retire using ��par�tAQn p�y
preference � � �r�d �v�i�,h my b°nesEis tc� k�e c�lc�rlat�d under this �r�fererce. �'lease �sse €��y 1ea�� in the
followir�g r���nner.
Run C�ut
L.ump Sum
uacati�n
��� V�C�ikafl
sick fE�atea-� �on�as hc�urs
`I'�y: y7sick � fiaaters I-� c= �Qe��is haurs
I un�rstanc� tha� rr�;� preference canr�ot �e char�g�d o«c� ihis forrro is si�ned and that my �ecisian i�
irrev�ca�le.
w EMPLaY�E'S S1GNaTUR�: --�:.-?--�.-�=-;-_ Z�: `��--=-i��� �=�_
� � _ � .:��'
ESSES:
r c� �
� - a
'�� ` / !`7'-r�i.���--
F2�dised 1 rG2
Fc,:m #?9G0-C+063
SQCfAL S�CURI7Y #:
Af�DR�SS� � t-� �, G� � t`� �_��,L�-� `�.; � €� �, , �,, �,� _, _
3 -
� � �;�, ..°���,� \�'� . �`�-- �,, �,�. � � �c- � ��
.�
PI-�Q�V�: ���-- �"R��---�c`��'l:� C7ATE: � —� �.U� _, ;�
r='sle Narne: E�aloye� 5er�arati�n Pay Pref
i1�Iernber ]]ata
ti'anze
Dat� ufiF�irth
rlge at Itetiremei�t
13enefici�rw� llata
Name
I];�te o f� S i rth
n�� at Retirenient
Ttetirert�ent Data
�3i�re r)at�
Terrri�natiot� L7ate
C;'fecti��c L]s�te
Fr'1�:
� o��tzi�bi�ta nns
I ntc;rest
C��yT af Clearwai�r Er�ployees' Retirer��nt S��stem
Senefit .�s�in��itc
JA11'iE5 �3E.�.RUSI.Ei'
0�11 �! 19�Fi
65 7'ears 0 P�I�nths 17 I➢aws
�iA\I]Rth �E:AI�US�,�Y
asro4���s�
57 Years 6 IVTox�ths 23 llays
a rn2r���a
�8f2412U13
49101l2U 13
S 42,I82.S�i
5 U.i)0
� II.G�
Social Seeurit�• No.
Sncial Security IVo
ILelatiarksni�s : S�ouse
# �f chilctren under 18 : D
Calc�ti�tion Ty�pe� 11_slimaic
F3eriefit Gmiip �;� N[�n-Haxardaus - Gran�f�thercd
R�tirei��ent `I�;t�?�� : Nnrmai Retirement
L7�7tioiy�,�lci,�d ' :
Paat�al�.� �1�r�n1 : SO.iiU (0 °/n)
i c��Nlcnil�er Seriice : 38 YeaY°s 9 IVlontiis 12 D�y�s
�. �:_ �
F«n��Eila �ar Benetit !1 2.75%fl � 38.7�333 years *�42��8�5�'`"-="°.
"m `';�
�� �
h s��
F'orrrr r�f PaF'menk '�� �� Fact�r
h?c���iial Forn1 ,::.��.. �' ! .[)I�C�OI]
`�in�le Life:��7nuity A ° 1.] i�8Q
10 Year G'ert�in an�i I�if'e lAnnuity "�� �� ,,���:,,, l.] 22?9
5C1�fo Jaint and Surv�r+�r .�:. }� u�` 1.0493C}
��"�u 7oir2t atld Siii��i��c�r � �=�'� f].�9�38
I(�{3°,�o Jr�int. anzl Sur�,�iti�or _ ''��' C7.9�G71
:�� y � �,
��^."}�,yrY
V��
rF
�
�
'!'7�
G.�
14Zvnthiy BenefSt
Patential
[v l�`�embcr Tv Bcr�eficiary
$3,744.12 NIA
��,� 1 � .��� �r 'r1
��i,2�7.�,1 N'?.
�3,]33.93 �l ,9b6.97
S3,i3 i _78 �2,�98.�34
�3,5��7.34 �3,54].3�
'`°['�i; r�sults tia�j�lay�d a�� fo� I€lilai['�iti��e E��;iiF�c,s�-; F?IlI4" �3i]CI i111ICS5 {:OlTl11318671s.`aii:C{ {1T�1�E"s�:is� ;hc�ufcl ill1l I]l: t�c�teci :is fti�a] rc5ults.
1'his calettlation is subjzct to carrectiat�. If you are c�r h�coine awar� of eiTC�rs in the r�ata that rn,°as tzsed, the calculatioris that tir zre
�alucfe, or the play3 prc�visions that were a��liecl, il is }�vur rzspc�nsibiiity tra ci��3tact tf�e pian aelministi�atat�. The plan has the ri�ht to
.•ecover from you ain��mis 4�at wcre paid cc� you in cn-a�.
:t9:�:'r.�:Fkx;k*:Ft��%cx;C4;:k*��c�rnit9c%tk� 1��1�J �� ��i�.�7 `d1'1 �5t1II�c`l�e �Y�k�k��F7`raFic�F#*;r:F;F:Et�¢;�; k'r.�*�'ryr*:k�;F
iiEtS BEnefit Lalciilatc�r (C322�I} - 1.f).�743. ]�3866 {]]�f141j II},y �g3 (i,'I Z.� 40 ] 3?:SFi: ] � Ph•I
G?T?° C�F C��ARVU'A7��?
PENSiDN Ef�TI�L�MENT C3PT1C7� F��C�Il�ST rQi�M
�I�fV-hIA�AR�QEJS QUTY �MPL47Y�E
E, ,J �-rr� _' � ___ �a her��y app;y ta receiWE �enefits un�er €he
��lease print na�r: }
Ci`y of C���rwat?r Gz��ral Em�l�y+e4s' F'ensian Pl�n in accorda€�ce �vith the foll��;.��in�:
Emplo;�ee !D # %� �' %
E3�te aF Birth: �%�,.,/�� ��� 5?
.Job Csassif;e�ti4��-�� .-�-,���= e. Tc
��p��trrrent; �`�?�4s �- ,���.-�-r..:.� �:�. !�•� ;:
Dat° o{ Hire: II/I � II y�`�' '�
B�nefits Effeczsv� Q�te: l�/� /?� � 1
---��-
Sp�us� s N�r-se: �-�.�UL�a
S�ouse'� Date of Birth: �
Gender circle ar�e): � � F
❑�visi�r: �,�_�s � ��L.�xt�c� r�..
�ate of Sepa ratiar:�: T��� i.:�
Spoa,�se's G�nc��r �circfe one,: 1v�
The type of ;��nsiQn far which [ am �pplying is �c�eck only one):
� Re�uEar Pensior� b�sed c�n years af service
Jo�-canr�ectEd D:sability f���nsi�r,
N�an-j�h-c�nnected i7isa�ifity P�nsi�n
The Cit�� o� Claatwater Ei�n�l�yees' Pensiori P�an pr�svides �nultipl� cptions to Pl�n P�rtic:�ants a� to #he i�nanner of
th� pensiGn ben�fFt payment. Opt��n 1 below re�resenis tl�e stan�ard or nor�r7�[ form ❑f reiirer��rent beneFit fc�r
Participants �ligibfe to retire prior ka .i��uary 1, 2013. Qptian � b�la��v represen�s the stand�rd c�r nc�rn�al forrn of
retir�meni benefii for i�artic�p�nts �ligible kc� rEk�re af�er Qec�mber 31, 20� �. T�e c�th�r �ptsonal f�arms (#3- #?i sha31
o€� c�mp�te� ta be fh� Actuari�l Equivalent of th� �rESpective norrnal �enefit.
��#aon 1- Joir�t and Survi�var �nnuity ��FJLY Ef elsc�ikri� to retire priar to_January ��4"�3]
An annuity paid rnonthly for ��� lif� of the Participant, 1r�'lih a 100`io survivar annuiy paid manthly for a p�ria� t�f fiv�
years FoVlaw+ng the death ❑� ihe Participant to th� Q�n�fici�ry; provided that foliawir�g s�ch fue year periad the survi�vQr
annuity shalf be r�duced to 50%� �f the or;ginal survivor annuify ar�c�unt. [See s�cti�r� 2.39? {aj �3} {1�.}] T��
l�a�€icipant's survi�Eng spous� r�ceives th� desigriated amou�t fflr th2 rest r�E hisli�er life �r ui�til helshe rem�rries I,
n� surriuing spause, dependent children un��r the ag� of 'I8 shall �� deemed t� be the b�n�fsciary and receive the
�,�ignated a�r�ount un#i1 the age c�f 18. [5ec�iar� 2.397 (a} [3} and SeciiQn 2.398 (b} t1)]
�ion 2 - Life Annuit
-�e Participant receives hislher pensian as long as helsne lives. Upon the d��th r�f ki-Fe Pa���icip�nt, benefits ceas�.
[Sectio�� �.416 {c; and Seeii�n ?.42� �b) (21 � � l
C� tior� 3-1a `�'ear Ceriain & Li�e Annui -�must desi��tate a 9�eraeficiarYj
The �ar�icipant receives hislk��r pensiar� as lorr� �s h�lsl�e 13ves. If th� �articip�nt dies �efore 12� mo�tl�ly �aymen�s
h�ve b�en r��de, t�e r�mairing payn��nts !�� io the �2a payments are i�nadP tc hislri2r b�n¢ficiary, �r the estat� if
his+'her �eneficiary is not alive. �5�ctior� 2.a2� ie�} (2} a. 2.)
0 Yian 4- 5D°f4 Jaint & Su�°v�vor �,nnui� -�rr�ust �fe�igrsat� a b�neficEa�l}
�he Participant receiu�s hislher pvnsian �s €ang as helshe faves. if th� Participant d�es First, the beneficiarV rec�ives
�C� p�r�e��t o� th� p�?�si�n far the resk �f the benefici�ry's life. ]f the �eneficiar}� di�s firsi, she Par�icipant rnay �Ic�t
an�th�r �eneficiary ar r�ay continu� to r�cei�d� 1Q�°�� af hislher pens3�n and �pon hislher dea�h, �enef�ts eease.
[S�Wk�on 2.424 (b1 (2) a. 3.]
�3�tior� � - 7�% Joit�� c� ��ruivor �n�tuEtY - ��rtlasi �F:sig���e � be�efi��at�+'�
�rhe P�r�ici��nt rec�iWes hislhe� �ension as I�ng as heJshe lives. Ig t!-�e Particip�nt dies first, th� ber,�fic�ary reeeiv�s
�5 �;erceni of the p�nsian for th� res� of th� a�n�fici�ry`s life. Ir t�e ��nefici�ry di�s first, fi�e Participa�t rr�ay eiect
an�at'n�r k�ener`ivaary ar rr�ay car�tinue to receive 1����Ia af hislher pensi�n an�f upon hisfher death, �enefits we�se.
[Ser�ion 2.424 �b} t2} �. 3.]
r � a-GS - r� -� �I s�.c� 7� r ..J L. > 4 .-,f�.-..�� 4 n`-§ C3/'Iti �E�7:.�_
31 Cti�Li[I� O�.JLlVfi'-i; J, ii,03 r, Iifi ��t :J�JiA.f::io ovutilVrl, ucji-:� �i�.`�_l_aiiU Li��:i::t:;F.iai j_._ ��(ve� ce.e •�y•
�O(:�ti�n �: _ � G���ri�t��cr'�: _ :�C�`,� .loint �n� Survi�rQr f1r�r�_iifi,+
_ �-- -
�r9y des�ura�ed penefi�;:;�:ry i5:
� ��
Na�n�: ���°?'-r-,:�'E-C�. ���z��% S�cial ��tc�a�i�j N�¢mber: _ �_
_ �I',+_ ,
i D�te cf Eirf.h: �. l�]�57�. � _ -- � , ��- j
G= rr��r �; C:ir�l=� CJne Ni �
-- —�- - �.---
�,dd��e�s: �'U r: '�- �r��. �-�,r::cJ:��"� �:.� �� . �'!? �G�?r�.f %`-�_ � y`� �
Phor�e hSurr�her: �� ��� `���
� `� �
�m�l�y�e's Skgn�rure: ' �� ��.-� wt�ti - -
_ �—
Dat� �; --- `���:r,�, �-.
1f takin� a Partial Lum Su� F'ayment, fifl in Percentage and sic�n �efaw: _
�p�i�n �k_ ___ f�,�± DeWcri�t��n: PartiaE ��.��np 5um Payrn�n�
I°lect to tak� a p�rtial lurnp sum payme�i in khe fallowing �m��?n� �ch���k �nly on2j:
10�Ia af the �ctua� ially d�.termin�d �al�.e �f the na, mal r�tirer�eni ber�efi`
20% ��fi .ne ��tu�rialfy det�r�r�sned u�iue �f the norrr;al retirement k�enefit
30°/� c�f the ���ttia�i�lly determin�d v�l��ie oi :'-�:: i�:;rri�ai �4:tir�rr;Pr: b�r�e��r
! underst�nd my rrant�ly retirem�nt �°nefit f�� thE c��tic�r� s�lected aaove sh�ll a� reduceJ accorc�ingly.
` E� �mt�loyee's Sig�a�ure.
[7at�
tf nasnin� a b�neficiar��Y, fi11 in ben�ficia�yy �r�for�r�atiior�_and sigr� bei�w:
h�Jly Jesi�naterj ren��iciary is:
Fenef�ciary f�azr�e
S�;�efcia,y Date of Birth: _
� Benefici��y ;��dress: _
I B�nLfciary P�ore �iumber'
�rnplo���z's 5igr�a�:ure: --
�
�
� IATE ��)L 3=LC��9D.�,
,.OUN�'s Y ��F
?I�IELLA.S
;=�e��. ��4f13
��rrr� �990���-nrrg
Beneficiary S�cial S�curiiy #:
E�e�n�ficiary G�neJP� (CircEe C?ne) M F
E�at�:
The �arzcaoing instrument w- �c�eno��vled�e� beio�e n�e ihis
l/� �
/ 7 �` �a�� es-t�. ; 2G''-�
a
bY .. - .�� � / —
�,��`�a is ersonally kno�r�rn io rne or � o I�as praUid�d �
�s G�icGtic:�: �nd �o dididici noi takv �n out}�.
C
���
_ . , :��aw�.;
,�f,�i�f ��`�7L�'L`JC [f-,
fl,�'r' �C�f`f"l;iliSSl�rl �X�II-E5. � �'-J �9
�r$�1 ii. c�a�oa��c�
�o�a��v ��
STATE £�F FiC�R1L7�4
, C+Oi117[17� �C�2��'��5
�P9s 7129/2a16
�1Gtaiy P�i�1ic
Rl�rn� �f PJ�ta� Printed
File i�arn� Pensi�r� �ntiileme�t Optior� r�rm
-1 i i i �.i e .. . _. : .%=+ i i �s , . . , �. � i
����o���s ��P,��� i ia�a ��;r ����=��E�c�s
: �:.y? �..� r t,� _.�"� f (.�:�J� � :�i �:X LyC:�
t ;
- . - � ..''�L�S���-,�
r������'�nf �� ,`�°�� Efil?��(ij!�t'S ..:?Cl i�C.�_�„c � IL!`.-, �U�T1 Fici'y'f7l �'flt ft7f Vc�3i.c�iiCUf1, 'Ci:1�:li i[_1 f1C_i'r�(J_3'y' ?ci! ..�iCi<
�C�'Vc If1C�1�11''V'�, �C?;l!1S C��!.'S I�If ��inIIC�C�I�} �fliCl "C?`� iii czC•+:;r�l�'� �':Ci�. +�'.c�'�J�- �t if�� �i,'1"1�.
o� s��:��-;ior7 i;'�r;� �h� City. Th��c �,r��i'I k� n�`� d����urt�c,n for pensit,n if-Ofi� in�s I!am�
sum p�y;r,�nt ncr vvi;? t��i� ���unt �.��ini as earnii��� in i:�e c��lr�ul��i�,n c* i���
�cf;�1C�1. ��,iE i�i5[ ��a� Gi 4°v�7rIC `yJl�! hL iilE F�fn`11T1�ti��f1 Ckc�`l`� �il� �cf1SiC7'1 ��fl�iliS 1^�'1s�
h�e�in ihe `c•;lry�v^;��r�y rn�r�if�.
�€��FEREI�CE �� En�pl�yee c�� e�rencl te�m,n�tiun �at-� by �art �r �II of th� L]ri�E �UC f�r v��caiior7,
Tloat�n� h�lia�y oay, sic�c le�ve in�en��v�, bonus �iays iif a�pi;c��bl�}, �nci �I!? oi
accrue� s:c;�. le����e. E�nplc�yv� m�y� �.h�csF to ru� CLJt �his t€me fr: �r,y+ r7��nn�r.
B�kan�� �.vi!1 be �ak� in � lumF� s�_r�� on em�lnv�e s fin�l p�yc�eu�: Termin�tior� dG�te
��ili �� i� � i r�al �a�y �i � i�n��c; ti��,�. Pvr��i:,n be�°�its ��rill �r�i;� .�7� ro�l���in�
mr�nt'�.
—_..__ - - ---- - =__.�_-�-- - - �— -
I, 3�t�==-�f{v`�: t�: '�'t���t�`��> ., an e�7��loy�� oi tl;e C��y� af Ci��r�v����, s�ere�a�+ �pply far �en:�ion
bEnefits �nr�ar the City's �r��playees' P�nsi�r� P!�n.
I h�r�oy �er#iry that l�L�IIy unc�erst�n� th� pref�r�nc�s affered �tc me I cf�:��se ta r�tire ���ing �e�ar����n �ay
�r�fer�r�c� � -� ar�d �ri�h,� m!�' u�e�;�fits io be cal�ulafed under rl�;s p;efiere�r��. Ple�s� us� m;�� I�av� i; � tf-�e
�all��+ir�g rZ�anner:
R�n Qut
vacat�on sick fla�i��s
�o�-��s haurs
L�m,� �urr� ��� ����� catior, ,� ,+�1_ t`��`� s�c�C i�a floatvrs . �I; � b�n�js l�ours
l u,,�c��rstand tl�at my preferenc� cannUt b� changed c���ce tl�GS f�rn� is �igned �nd th�t rr�y decisitar� i7
�
ir�.���.����b14. �
c'' � i'�.� P LDY ��' S� I G�1.4.1 IJ R E: ���->-.�-� i� ��.--
SCiCI,�L. SECURITY;�:
'�"ti+i � ivES�F�: AGG}R�SS:
� ,��;;�..:�� . _��.�� ��:�' �
I 1 I� i Y L.
pEVI�°� 1�u'2
F�r;�i �5+9�C�—�Q��s
,
Q�t'�5��� �+�� ����
� i;: �same: �m�loy�e S�?ar2=ior: Pay ?re�
�������� �����
r:��,l�
n��z t�r r�����1
��e at Retireme�7t
B�e�ze�ci�rv l��ta
Nart?e
L]al.e �rF F3irEh
r�QE'� Eit �i:CIIL111.Z1�T
�.��IY`�I�YEII� ����3
Here L�atc
Ter+.nination 17aie
LfFe�tst�c f.lale
r n��
Ce3nirit��itit�tls
r��cere,t
[��t� ��° ����r��t�� �rrtp��y���� ����r�m��� Sy���m
�er�efi� �s��r����
��ir��Ees 1r`r��.�r�
�i� i'ears I4� ]4'inntlis 5 Ua��s
Y:�NFT NIILNE
59 YQa�rs 5 14T�nti►:s 4 I�ays
fl 71DSr` 1'�93
o��z��zQ�����i•�:; �r���i��
[}$f4l!��i3
� �33,QI6,1�
� f1.40
� U.OU
sac��al se�.�irsri�� Nt�.
5r�cial Sec��rit;� Nn.
R��ht�on5hip : Spausc
n of chilc�ren unclG.r 18 : U
C.alculati��n Ty���v : �s#imate
}3cne�t Gr��tGp <=, : tia�ardaus - �r•andf�thered
ltctir4mc:nt `f'��Se �;: : Norni��l Retirement
C�ptic�n �i�c��d
F'arti�I ��a�t,�l�'S�tt77 `�[1.4[} tf} %}
T�t�I;TVTe��,er 5crti•icc : 2(l'Y'e�rs 0 Nlot�t�is 19 Days
�;
Fc�rmt�la far Be��e#it �. : 2.75°/6 x 20.[k�2$ vears '' �K3,Ui�;�B =�� a
Form t�f �'�vrnee�t .= � k��.` F��tor
�471-Ii7�1 1'O]ll] � 1.Q'(}{��'d
Sin�le L.ife F�31i�L�it}' 1.17C}4I
I[? Y�a�- C.ci7aA3� ai�d Li#e A37ouity� �'�'�� �> 1. l](i�0
�Go,r�.I��inl �an(1 S�.ir��t�'n�' � `�� ,�x' I,[}�iC}.i
�5� ?,'3�',u .faiz�t and Slzrl�i� c�r � �: °'��` l,Ol �9 i
?�`;i, Jc�iAit and Sun•�i��a�• �'��"`� ` 1.002,'• j
i[]U�'.o Jc�i�lti atid 5trni�•or '; ����,. 0.9S70C�
�
(D
�
�
W
Manthly Beneft
�'vtesatfal
'L'o Pvlembee° �E'o Sene��iary�
°53,�1 �.'�ti
54,4�;5.f}6
��,?58.?�
S�,Cl] �.'?b
5i;h�i.32
53,�32�.4'
�3,6i 1.1?
���
N?A
Nr':�
S� �UOti.{i3
�2,5'31.; 5
$2.8�9.U8
$3,651.1Z
F ;. , , , � . , . �:.! `?:�.
�: f« •L••,u,t� .:ly�sst?t .�.. ;i.rv fi±r �Iltt,t�.��u�.c� �7�.0 �?ca5cs �anl� ��1;+� �'s�71�„ �i]1:1;11un�C�3.ti;ci �iYhc.t`t4'fsc :;ht+u.�� r•.4,t i.i !�.�at.�tl �l. :i�, t,.:,Lt3
I I115 C�3.�L'11�1T1(3i1 IS SLI�)� �CT �D COITEC�l10ii. It �;'QLI 2C2 f7P }Jc'Cp111Z �1�'�3.t'�� D7 Lii[3i4 iP. l}?2 C��fi3 t�7�3.i �1��15 Lf4i.C�, T�1L'� C�3�CLi��1TFOt�15 1.f1dL EVeT�
m��ja, «r lt3e �lan }�ri�visioiis tl�at +s'ere• ap}�lie�l, it is �.rour resp�itsil�ilit�+ ec� c�ntact tta� plai� adi�linistr:xznr. Tl7e }�lan'�as tE�e ri�ht tn
rcc«a�r Fr�rn v��u atilnunts tl�at �aei•� g�aid t, ;�ot� ir� �:i�ror.
;':ic:cic&:�f.::z:�:�k-Y.r.:c::•:'rkA:k9:x*-f;*:':�.:� �'�-lt5 1S i�Ilt r`Z.il L`S�IiI�`c�&� :�9;'r.*�k'r,i:nx�':�kakir�:'r,ic*:':r-�:'�..�.-�:kk�
�'
CikS Lie`nefEt C'a€culaii>r (C'i�'29) - l.f1.9143. EybCifi ( I�41�11 iLT?t 311 ,-i'2�`ZU1 ;�J:S 1:52 A�G
Ci�Y t3F �LE,��CiNATtFs
P�NSI{]N EIUTITL�NEENT �PTI�N REQ�IJES'1` F+C7i{M
�lAZARDDUS bUTY �MF'LC7Y��
v_..� ; r_.. ; _, . .-. . ;; � . . ,.., .�:
I, �>�-.`= r`'�'_s:.-- ;,�-., :,:�:, _ do hereby �poly to receive benefiis undnr the
��lease print nar�ej
Ciiy nf Clearwater Ger�eral Ernpkoy�es' P�nsio� Plan in �ccc�rdanc� with the folfowing
Employee IC] # '.� �.�'f r? � —
[Jat? c�f Birth:
Job Classific�tion� ��[:' 't°��-�'_ '�';.:-;�-��.'�-�"�
[�epar�ment: �'�.-1 �C �.
[�ate of Hir�: i � `� � d'[�' +
�- r� ":.� : . i
Ben�#its �ffee#ive Qate: `j`, ; _ •' r ; +_�
�'��,
�Gender (circle or�e): �'M,, F
,� _,,
�I�19S3C)f1: �,�U�� �"<�;
Qate of S�paratio�:
_���'1 �'"f-
Spous�'s IVame: s`;_'� �_tr,:� ��-�.;, ��,l..ti� .
��
5pouse's l7ate of t�irth: Spouse's Gender �circle gne}: M: F;
The iype c�f pension far which ! am a�plying is {check o�afy ane}:
�,�� Regul�r P�n�ion �ased pn },+ears of service
r�O�-��f1�E.GtELi C'ijcahilit� P�?nSinn
I�on ja�-�onnected Disa��lsty �ension
� he City of Clearwat�r Employees' P�ns�an F'lan �rovides m��tiple options ta �lan Participants as fo ihe manner af
t17e pensian b�nefit payrnent. CJptfon 1 belaw represents fhe s#anc�ar� or r�armal farm af retirement k�enefit. The otl�er
optiort�l fQrms t#�- #7} shall be comp�ted to �e the Actuar9al EquivaEer�E t�f th� r�spectiv� nr�rmal benePit.
�Opticsr� �i - Jeair�t ar�cl �unrir�or �r�nuit�r
An annuity paid monthly for the life af the P�rticipant, with a 1 �D% sunrivor a��uity pa�d montf�ly for � period of ff�re
y�ars fe�llpwing the d�ath of the Par�icipant �o tF�e �eneficiary, provided tha# fallowing such fi�e� year periad the survivar
annuity shall be reduc�d #Q 56°/o af the or€ginal survivvr aran�ity amaunt. �See s�cti�r� �.397 (a} (3} (Aj� Tf�e
Participant's surviving spous� receiWes �he designated amc�unt fr�r the resf of hislher life nr ur,tif helshe remarries. if
no surviving spouse, dependent children �nder the age of 18 sha�l be deemec! to be the beneficiary ar�d receive the
Jesigreated amount until the �ge nf 1�. [Sectic�n 2.397 {a) �3} and Secfion 2.398 4b} {1}]
�
tion Z - �ife ��n�it
e Participant receives hislher pensian as lo�g as helshe ]ives. Upon t�e death of th� Participant, benefits �ease.
e�tion 2.41E (c) and section 2 G.z�1 i:b} �2} a. 1.]
�+�tmea� 3 - °EO Y�ar Cert�in & Lifie �ene�ui�y - �ma�st �esigr�aie � t�en�fi�sar�j
7he P�rticipant receives hislh�r �ensinn as kflng as t�elshe lives. If th� F'artfc�par�t dies befflre 120 month�y pa�m�nts
have been r�ad�; the rerr�aini�rg �aymen�s up to the 12� payme�rts �re �ade in hisfher beneficiary, or the Estak� if
�rislher ben�ficia�y is not alive. [S�ckian �.424 (b} f2} a. 2.]
Opiian �4 -�0% Joirtt ��urvivor Llnrr�itv -{m�s� designate a b�nefi�iary')
The Partpcipant r�cei�es f�islh�r pension as long as helshe fives. ff the Participant dies first, tf�e �eneficiary r�ceives
5(l perc�nt o€ the per�sian for khe r°st ai the beneficia�}r's life. If t�e t�eneficiary dies first, the Participant may elect
another beneficlary �r ma� c€�ntin�e to recei�e 1�C7°lo of hislh�r pensian and upar� hislher death, benefits cease.
[Sectian 2.42� (�] t2) a. 3.]
C� t�os� � � ��°/o .9c�irot & �a�rvi�rar An�a�it - �r��st designat� � ��a�ef���ar�'Yi
I ne Participan� receives hisf�er p�:nsion as 14ng �s helshe lives. If the Particip�nf dies iirst, the f�en�ficiary r�ceives
75 percent c�f fihe pensian far the rest ofi th� beneficiary's life. If the benefic�ary di�s fi�st, the Participant may el�c€
ane�ther �aeneficiary or m�y contir�ue fa recer�ie 1��°Ia �af �islher pension and upor� hislher de�th, berr�fits cease.
[Sectian �.�24 (b} t2} a. 3.]
i] tion 6-'fOiJ°Io Joir�t & Surviuor Annuit -[rnu�t desigr�ate a[�eneficiary}
1 h� Participant receives hislher pensian as lanc� as helshe lives. li the Pa�ticipank dies first, the beneficiary r�ceives
1 C]{? �ercent of the p�nsion fpr the r�:st of the bene�iciary s lif�. ff the heneficiary dies first, i�e Partici�ant m�y elect
anoth�r ben�ficiary or may continue ta receiv� 1QG+°I� of hislher pension an�i �pa� hislher �ieath: benefits �ease.
[Section 2.424 (b} (2} a. 3-]
4pii4n i— a& Zl3°I� Joint & 5urvi�ror Annuity -�must d�signate a beneficiary}
�he Participant receives hislher pensian as lor�g as heJshe If�es. If the Particip�nk dies €irst, the �enefici�ry re�eives
66 2/3 pe�-cent c�f thre pensian for th� resk �f th� beneficiary's lif�. ff the beneficiary dies firs#, the �'ar#icspant may elect
�nother k�enefciary ar may co�tinue t� recei�� 1��°/o af hislher pension �nd upan hisl�er deatl�, b�nefits cease.
j5ecti�n 2.��4 (b} �2} a. 3.l
Partial Lum Sum Pa ment C3 tivn
A part�al lump sum p�yment �qual #� either ten p�rcent (10°'0}, �venty percent (20°fo}, nr ti�irty percent (3(}%� of the
a�tuarially �fetermined value of the norma4 retirem�nt benefit due the member m�y be elected in comt�in�tion wvith any
of the options irrdicated a4�ave. l# a member elects such a partial lump sum distribufian, thren the monthly retir�ment
b�nefi# for the c�ption selec��d s�t�ll be reduced ae�crdi�,gly thbr��fter. [Sectinr� �.424 (b) (2) a. 4,]
I have considered the variQUS benefit paym�r�t methods un�er su�h Plan and have �lec#ed tQ receive my r�tirement
h�nefits �s indicated belaw. {Note: C}ption selection to be indacated both by P�umber �nd Description.}
!�andersiar�d �t�at once my first pensian c�eck is r�c�sv�ecl, rray d�:cision on thas ��atiran is urr�vocak�le.
It takira�g i]ptE�n `a
Option � �
Em�loyee's Signa�ure:
t�e�aw:
Description: Joint and Sunrivar Annuity
Date:
Dep�ndent children under the age c�� 18 and residing i� my hauseh��d a�e:
Child's CJam� Gender {iV�-F} aate of Birth Sacial Security #
�f taking Optia� 2 �ig
l�ptipn #: 2
�
�'rnpl�yee's Signature:
�e law:
I$ �ai£liii� L3�]iYOSI 3j Y191 h91 37�ii�YIC
�ptian #: 3
My designat�d k�enefkciary is:
�fame:
Dat� of �Erth:
Address:
Phor� �Vum��r:
�mp[oye�'s 5ignature:
Des�cription: Life Annui
C]�te:
I I � 1[U � t�Y L'1'L�l�f �=Yt C� E-1L EIl)i�3 Lil +*�
aescriptian: 1 D`�ear Certain and Life Rnnusty
5acial 5eeurEty 6�u�mb�r;
Cer�c�er (Circle One} M F
P�I�tiQrtshi�
�ate
if ia�ir�c� G�a�ic�r� �, �, Grl7f �, fsi� i�a a�ptio�+ �u�ta�r, L3�s�ri�fi�� �rc9 ��n�fRC�ary gnfo�r�a�s�n �nd �E�� 3��!s�vs�:
C)�tion #: � �escriptior�: �+'�-''' '°Io Je�ir�t and Surri�ar Annui
My design�ted �eneficiary is:
fVarrle: �,d a��� � �, � %Yj', a.�'€ �
Date af Birth:
Address:
Phone Nurnber:
Ernpkoyee's Sigr�ature: �- ��.�+ ( � �
Sociai Secursty �Jurnber
Gender (Gircle Qr��} M �
F�eiaiionship
r.�.� � F E
b at�: � ' � ._ � � r 3
!f taking a f'artial f�ump ��m r��yrn�ni, riii in rercerazage anu sagr� ���Uw:
C�pti�n #: NA �escriptkon: Parkial Lum Surr� P�ment _
I elect ko zake a partial lum� s�m payment in the follawing arnount {check on�� an�3:
1�°/Q af the aetuarially determined val�e af the narmal retirement benefi�
2Q°i4 of th�: actuarially deferrnined vafue of the n�rmal retiremer�t benefit
3Q°Jo af the actuarially determined value of the n�rmal retirement k�enefit
I[ undersiand my monthly retire�nent benefit #or #he opti+�n sel�cted above shall be red�ced accor�ingly.
I Ernplc�yee's Signafiur�:
Ifi namir�g a kaen�feci�ry t�BVLV, fil! an
My designated benefician� is:
Beneficiary Name:
B�:nefieiary Date af Birth: _
Benefcsary Address:
Bene�iciary Phone Number-
��p[ay�e's Signat+are:
�T�TE OF FLOh�1C��
CQIJfVTY OF
PINELLAS
�,t►�'Y �,q� f�olary Pub�ie State tdi Flarida
o G'sr+a F inests
�� kLSy Camrriission EE 20#34�
9f � ExP�res a8l�312D�E
t�a#e:
i�fvrma��oea ��d sir�n below:
_ Beneficiary Saefal Securify #:
Ben�ficiary Gender (Circle Dne} M �
Relationship
Date:
The foregoin� iE�strurnent was �ckno�vleJ��:d ��ior� ir�� �his
-- ' � day of `�� �'-C-. „ 20=--
_,--; , � y
b,y �. ,.--.� Lr.i -..- Z;.��_.�..� �� / _ r s . , u� `+_._
S , t - � �`�- _ E
w�ho �s p�rsanally knawn �a me ar vvha has provided _
�s identiflcation and who didfdid not t��:e an aath.
�� 4i4-'��'�-•_- ��� ._�\ a.� ' �� �i7LAdl�1 �U�7EIC:
� �.�' ;,k �; �K.. _� �� -- ��
'z �. � ti- -
My Cammisskon expir�s: ��% ` "` '! — 's `
N�rne of Notar�r Printecf
Rev. U411 �
Fo�m �99C1�-nGC�9 File Name: �'�nsiar� Eniitlem�nt Qpfion �orm
�i i �' i1� C��r`-er�Y�,� i �rc
E�IPIPLC]YEES' SEF�ARATI�QN PAY PREFEF�E�C�S
PREFER��tCE #'t Emp�oyees c�n re�eiwe � 1ur�p sum payG��nt for �acatiorr, fiQ�tin� hQliday pay, sick
I�ave inc�r�ti�re, �30C1U5 C�'c��15 �lf �{]j7f1G��3I�}, �nc� 'l f2 of ac�rued sick {�a��e �t the time
af separatfon from the �City_ There wifl be na deductEon �ar pensian frorn thi� l�r�p
sum payment �or wi11 this amaur�t caunt �s earnings in the calculatian of the
pensian. TYae last t�ay of work will kae the termi�atian date and pension benefits wili
began the fallowing manth.
PREFERENCE #2 Employee can extend ��rmin�tion date by pa�t or alk af the tirr�e due far vacat�an,
floating 1��iBiday pay, s�c1c i�aae incen#ive, bonus days (if ap�l3cable}, ar,d 'l12 of
accrued sicit I�ave. �mployee may chaose ta run �ut this tim� in any manner.
Balance will be paid in a lurrtp s�rn on employee's final paycheck_ Terminatirn d�te
will be the �nal day af extended time. PensioR bene its wi�i begin t�e fQilQwing
month.
-
..�35 i� � . - .,...... - . ..
... ._. � - _ . .
3
I, G,l� I'1� .�.; , an e�playee of the Gity of Clearvvater, hereby ap�ly For p�n�io�
faenefits under #he City's �m�layees' Pe�sion Plan,
1�ereby certify that �#uily underst�nt� the prefer�nces offered ta rn�. f c�oas� io retire using szpar��ic�n p�y
prefere�ce #�� �nd wish my be�efits ta be calcuiated un�er this preferenc�. Please use my ie�ve in the
foilowing manner:
Run O�t
�l�ili�7 �UCI`1
vacat�on
� L) n ' Vc`3C��1dI1
sick f3aaters
l� ��. i�ick 3� f�oaters P
��C'�na�
banus haurs
bnn�s �ret�s �,�}+�
I ur�s�rsta�d that my preference �annot be ch�nged �nc� this form �� signe�{ and th�t rr�y decision is
it-i��v�cable.
EMPLUYEE'S SiGNP,TUR�:
SC)�IAL 5�Cl1RIT'r` #: 1
� TN�SS�S-
f�
I�C7�3RE5S: �__-
PH�NE:
QATE: '� "t'� `��
Refiszd 'Gl02
Fosm #5�a[3-OOQ8 File Namc: Em�loy°e Separa���r� P�y Pr�f
"��TemheY- Data
N3rr�e
T?ati; U f 13 irth
,�ge at RetiF•emez�t
$$i7�f1C1�]'V ��t�
Naine
]]ate c�i �3irth
r'��� at Retirerrieeit
I�etiremen�'��ta
I�irz Date
Termiijatian Date
F_.ffective Date
FAC
�o�t�; �„�t;ons
Fnterest
Csity �f �i���rr�v�ier Err�pZc�ye�s' .��ii�-������ Syst��x7
�ene�it E��imate
R�C�.4121) CT�E,�i�
1z���fxs�1
47J0212613 ���';L�� ���+rr(��' ��
o�iazi2ol�
� �1,96�.96
� O,U4
� O.Ofl
Fozmula for 13ene�t A :�.75% m'� 2I.505G years *
S4cia1 �ecuriry �c�
Sovial Seeurity No.
Relati�nship
# of children un�ler 18
Ca�cula#ion TY'�;
}3enefit Group
Retirement
C?r�Cion .� ec d '��
�'artia .
T�a�� Tei � er Service�
For�n of Payment �a����'
�lQrmal For�n 1.flOG49
5in�1c Life r'�nnuity 1.���`��
lD Year Certain �nc� Life Annuity i,6�1f}[3(]
tirr£�,n �o�[315. cit:�i S�tirc'�:F�`t]r
si{� �:�g"'�� Juzi;t <>>z�i tiun'€��or
.���°.i� �C>111[ :1xC; �il'"v1VC71-
I t�i3���o .�i31P.1. itl i. �sl!I'L't�,.'{jl.
�
�
�
W
�
��
XYY-X�
Es#imate
Hazayelous - [Yrandfaihered
Normal netire►nent
��.�}� '�� n�is�
21 Years b Mnnths 2 Da��s
Mr�nthly �iene�t
Potet�tial
Tn Member
�4,5 b 1.;� �S
$?,5b 1.88
�4,532.�6
Ta 13eneiiciarV
T�IIA
�.; r,�
?�TIA
'�T�e results disp��y��ci are for illustrati�e ;�u_rposes c?a�ly and unl�ss ct7n��7ruiiica�e�1 otl?en�•i�e shu�il�� n�[ l�e t�eaied as final resu.its.
This calcu.lat�an is subject tn correctioi�. If; ou are or l�ecome awdre oi prxnrs in th�: daia t}lat was tt�eti, ihe calct�latians fhat w�re
ni�d�; c�r the plan pc'ovisions �i�at �vere ap�lieci, it is yaur responsil�i�ity ko cania;.t the pla�l adrninistrator. T'he plan has the right to
recnver frnrn you amv�ais that ��ere paid t� y�u an errr�r.
�:;$„'r.:F-.�:*i:iiicsY�:F;':ti-;�;�:zx�r',°.'µ.Rir�:c:cir This �s Clnly a.n Esti��.te XK"yc>:9c�*�� :-*-k�ki:xYcr'.�7r;c��rici;�cr,-
[�R4 i�Qne�'ir C'aScul�tr,rlC:32391 - 1.{�.�k7�'3.L'�86o [1��99} �L3:�, 296 7f1.r20�3 &:52:{1& AVl
C1TY PF CL��RWATE�Z
�'ENSfdN �fV71`�L�MENT OPTIG�N REQUEST FC7R�111
�-IA;ZA'�DOUS �L3TY EM�LOYEE
--�� �,.� �] ��(� _-,�.� da he3eby a��pl'y t� recei'vc k�ez�efits ur�caer th�
I, i ���-. _
Ci� Q# Cl��fl^Jater General �rrployees' Pension Plar� in accard�nce wi:h t�e fall�vti�ing:
Date af �irth: , Gender {circle one}: � F
Jt�b Classificati�n_ _�� C i�� C'���'� _ —
D�partmeE�i: r�[ � r� � �... � E--Y-,-t.�� Divisson: _ �/ �,� � �'�-"�";2 � �"
Uat� af Hire: 1 z- 3n -�t - �ate a�S�paratian: �'�-! -!
Ben�fits ��ective �ate: �/ ' !� _--
Spause's �lame:
Sr�ause's D�ie afi Blrth:
5pouse's Gender �circle oneJ: M F
The type af pensian for w�lch 9 am ap�lying is (eh�ck ��ky ane}:
� Reguiar Pension based on years of service
Job-connected C}isabilit�,� Per�siors
Non-job-cannected ais¢bility Pensian
The C�ty r�f Cleannrater Employe�s' Per�sian Pkan �ravides multiple a�tions ts� Plan Parti�ipants as to tf�e manner �f
t�e pensicrn berie�Et paym�r�t- �pfkc�n 1 belaw repr�s�nts the standard c�r narmal form of r�t6rem�n� benef4t. The other
r�ptional farms (#2- #7) shall be c�mpute�i t� b� t�e Actu�r�al Equi�,rafent of the respective normal be�eft.
O�tivn 'f - Jaint a��d �urVivQr Annui
Ar� ann�ity� paid monthly fic�r the life Qf the F'a�ticipa�rt, �vi#h a 1DQ"/a sunrivor annuity p�id monthfy for a periQCf of five
yea�s fo9lowin� the deatl� o,` the Pasticipar�# to ihc benefciary; provided t�at fol4awfn� such �ive year period th� survi+rt�r
annuity shakl be reduced to 5�% of ihe arigin�l s�rvivar an� suify amaunt. �5ee section 2.3�i' 4a} �3} �A}� The
Participant's surviving spouse r�ceiv�s t�e de�lgnat�d arna€.�nt for the rest of hislh�:r life or €�ntil he,�she r�marries. If
no survi��ng spouse, dep�ndent chil�r�n under the ag� Qf 1�3 si�all be d��meef t� b� the benefciary and rec�i�v� tk�e
d�signated �mour�t until the �g� of 18. [S��tEOn 2.397 [�} L33 and Sectian 2.398 ��} ['f )l
D�t+an 2 -- Life Annuitv
�e Partic�pant receives hislf�er perssic�n as long as hefsl�e lives. U�on the dea#h of th�: �artieipar,t, b�n�f�ts cease.
ectiors 2.� �l6 (c) and S��tic�n 2.42� {b} �2] a- 1-1
�
�ptian 3 - �0 Year �ertain & �ife Annui - {must desi�nate a benefiiciary)
�he P��iicipa�t recei�rPS hislher pension as lang as Y�elsh� lives. !f tk�e Particip�nt d4es �e�c�re 1�fl manthly� payments
h�ave been m�de, the remaining payments un to th� 'f2Q payments are rnade tQ hislher benefifciary, Qr the esiat� if
hislher b�nefi�iary �s r�at aliae. [Se�tion 2.424 �b} (�) a. 2.]
Optivn 4-!5C]°In ������ & SurviWar Aronuity -{must d�sigrrate a b�neficiary}
The par�E�ipant r�ceives hislher per�sian �s I�ng �s hershe lives. E# the Pa�ticipa�k dies iirst, thE benefi�i�ry r�c�ives
50 �ercent o� €he pensiQn �ar the rest of the b�n�fic�ary's life. Ir` the �enefir��ry dies frsz, t�e P��iicip�nt r?�ay �lect
andther benefscaary ar may cor�tinu� to reeEiVe 10fl°.�fl of hisiher pensian and up�n hisiher dea�h, beneFits cease.
[5ection 2.�24 (bj (2} a. 3.1
f� �ic�n �- 75%a Jaint & Surv`rv�r Anr��i -£must designaie a beneficiaryj
The P��ti_r,i�ant rec�iv�s h3sr'her pension as long as hn�she li�es. Vf the Pa�ti�ipar;t cs`ies first, t�?e be�ieficiary r�ce�vEs
?5 perce�i of t;�e pens�on f�r the rest n� the �eneficiary's �if�. Ef the �eneficiar±� di�s iirsi, the Participant may el�ct
anath�r ��nEric€ary flr n�ay continue t� receiW� 1DQG�� of n;s?h�=,- pensit�s� and upb�� hislher de�th, b�neffts cease.
�Sectian 2.��4 (b} (2} a. 3.1
Drtior� 6- 104�'fo Jo�nt � Surv�vor Anr���i - tmust �esignate a be�eficiary}
i h� P�rticip:��'�k rec�i��es his,�'si�r �ensiar� as 9oraq ;�� he;��'�e liWes. If thE P�rtici�ant dies �irst, �f�� btinefici� ry i-eces��+zs
1C�� pe�-ce��� �f zh� per7sion i�� �I�e r�st �f the aenefciaiy's li�e. Ir khe �eneficiar, dies fisst, `he Partici�a:�t may elect
ar7cther �en�iiGiary� �r n�aV �oniinue to ��ceive 1�{]�I� ar' his,'h�r �aensinn and u��n h3slher �fe�t��, be�efit5 cv�sE.
[��cti�n �.42t ��al (2;� a. :�.]
DptiQ� 7—�6 �fa°/o Joit7t c� Suryiv'or Annuit� -{rr�ust d�sigr�ate a b�neficiary}
-1-hw Par�icipant �e�eivves hrsEi�er �ension as long �s h�!she ii��+es. If thv �a��i�ipani cikes fi;si; t�e b�nefciary �ecei,���s
�6 �1� perc�nt of th� �ensic�rz far the re�t of the benefciary's IEfz. fr` �h� bEnefci��,� c�i�s frst, the Par�icip�n# �nay �lect
anather be^wficiary or may continue to ��cei�e 100°I� nf hislher ,�ension and u�on hisli�er �eath, benefit� c�as�.
�5ectian 2.424 (b) (2} a. 3.]
Partiai �um 5urrs Pa ment � tion
R pa�tial lurnp sum �i�yment eq�al to either ten perceni �1C}%), tv,�eniy percent {2C]%), or thirky peFCent (3Q%� af the
actuarially deterrr�ined vals�e af the normal retireme�t benefit due the rr3em��r r�ay be efe��ed in �ombi�at�on wikh any
of the optians indic�ted at�ove. If a member �lects such a p�rtial lumr� sum distributEOn, t��n khe monthly rekirement
benefi# fr�r th� aptian selecf�d shall �e reduced �ccordingly �here�fter. �Sectyan 2.424 (b) (2) a. 4.]
1 have c�nsid�red th� various beneft payment methads under such PSan and ha�e elect�d to receive rny r�tirement
�enefits as indic�ted belo�v. {N�tE: Cpti�� selection ta �?e indicat�d �Qth by �lurn�er and Descriptian }
6 ��nderstara+� th�t or��� rn;+ Tirsi �er�sion check �s rec�ivea; r��i� eiecisior� c��, this o�#ian is ir� e�aaca���.
If taking Optian '1 sign belaw;
�pEian #: 1 crip i�__ Joint arad Survi�ar Ar�n�
Er��pl�yee's Sign�ture: �. '�—� b�
1 Geper�dent childrEr� �irsder the of 18 �r�d residi�g in rr�y hcuseho]d are
Ch+id's hlarr�e '� Gen�er D�te o
� ���' r�� r �.� �-rJ — � _ —
7� /�r�� �1` �'.�'�^i � -
� �{� � � � � G r� ^- � ._�
ff ta�Cinq Option 2 sign belo� ���`',i�s �-e_�,.� �
Qption #: 2 �JeSrrk�7ki�i?: f.�lf2 f�liC1L11'{y _
ployee's Sign�t�r�
kinca Otation 3, folf in benefQCiary informaYian a��c� sign belc�w:
❑ ate:
C��at3an #: 3 Description: �'10 Y�ar Cer�ai� and �ife Annuit�
Niy design�te� Lpr�fciar�i i�
iVame: _
pate of �irth:
Address:
PhenA Numb�r: _
Empla!�ee's Signature:
Sacial Securiiy Number:
Gertder (Cirele Os��] M F
'�ate:
ff takin O�aiion �, �, 6,or 7, rilk in 4�ptior� �lu�it��r,-�escri�t�or� ana_iaen��rici�fv ir�torn�atic�n an[� sic�r7 i�e's�w_
C]p`i�n #: _ C�escri�tEan °/� Joint a�r� �un�'i��or �r.nuit
1��1�+ desigr,at�c� �ei�ef,:iary Gs:
l�amv
[3�i� C�f Birth:
Addr�ss: __
Phane 1Vumber:
Er�pl�y�e's 5i�nature:
Socia] Sec��rity i�Eumber:
Gen��r {Circl� CJne) ��l
i7afe:
If takin� a Partial Lu�rtp Sum �'a rnent, frl! in Per�enta e and si rt belaw:
Op#i�rn #� i�A _ C�escription: Parti�l Lu�n 5€�rn �'a rr�es�t
I elect tQ tak� � pa�tial lump sum payment in the follow3ng amount [eheck c�nl}r on�):
1CJ°/o of the actuarialfy determineci �alue of the no�mal retiremenk beneft
2a°.� af the actuarially determined value �f the norm�l retirement �enefit
���'lo ❑T i�i� c']G�L12C1���]I C1°i�ff!14nc�ri �,rafr ia n# t}7� r-�ns ��1�? �-E�irel�'te�t �ie�+�fi�
f understand rr�y mcnthly retirement b�neft fo� the optian setected above shaf9 �e re�uced accordingfy.
EmplQyee's 5igna�ure:
'�ate:
If n�ming a ber�eficiary C�NLY, fill in ber�eficiary informativn and sign belc�w.
My designate� benefciary is:
Ber�eficiar}+ f��rne:
8eneficiary Dat� of BirtF�'
Benef�iary Rddress:
�eneficiary Phane iVum�a�r:
�rr�Pl�y�e's Ssan�t+�re: !
�
W
S1 ATE �F FLCJ�IL�-A
CDUNTY C?F
PINELLA�
Bene#ici�ry 5acial Seeur€ty #;
B�nefciary �Gender �Circle Qnej M F
Q�t2'
i
Th� f�regaing ins�r�rnent w�s ac�r��vdledged befare me this
�5� T d �y of �i.Ut�t�, , 2a ��
by !' ;I��r_7 �� `�"r
wna is persanally knowvn to me ar �rrh4 �as �rc�vided _ _ _ .__
as ider?tif�cation and wha dic�ldid n�t take an o�th.
Na}ary Public
��`;�` .� �j �s .!l _ Nar;�� �i Notary F'ri:nt2�
My Co:nrsiissian ex�i��s: � �3 �' u_
� y �1lCHELLE Kl� i CFi
R�v. �J4i13 I��T,4FiY P�J�3�IG
�an� �����-��0� ST�T� t�F Ftoe�loA File i�Jar���: Pensi�� E�titfemeni C�ption ��rm
o c�� ��zo��v�
E�cpires 5l2312(3��,
l.i I i'' 1�F �'.L�/�1r'�il'►�iHTtrC
EMPLC3YEES' S€PAF�TiC7N PAY PR�FEI�E�CES
PRE�ER��10E #1 Empfayees can reeeiwe �, lum� surr� payr�e�t f4r vacatian, ilaating holiday p�y, sick
leave incerrtive„ honus days {if applicable), anc# 112 of accrued sick leave at the tirne
of separation frQrn the City_ �h�re wifl be no deduction for pensian fra€�ri tt�is �ump
sum payment nar w�Kl this amour�t count a� earr�ings in th� calculatior� of the
p�n�io�. The last day of w�rk will be the termination date and pension b�rse�ts will
begin t�re faliow�r�g �onth.
PREFERENCE #2 �mployee �an exter�d terr�rnation €�ate by part or a�1 of t�e time du� fra�- vac�tion,
fl�ating hoiiday pay, sick leave ir�eentive, bonus days {if appiscable}, and 11� r�f
accr�ed sicic ieave. Em�alayee may cE�caose ta run aut th3s time in ��y manrrer_
Balance wil9 he paid ir� a�ump surn an �mplayee's final paych�ck. Termination date
wifl be the finai day of exte�ded tirne. Pen�ic�n k�enefits will begin the following
mc�n��_
� __
_, „,�
I, �� ��'r� �f''�,�d�I __ , an employee af the City of Clearwater, I�ereby appfy ffl�- p�n�ian
k�enefiis uncf�r the Ciiy's Ern�loyees' Pensior� Plan.
I h�r�by certify that I fully u�derstand the prefer�nces c�ffere�i to me. I chQrs� to �e#ire using �eparation pay
preference #�_ and 'vtirish my benefits to be caicu�ated under tl��s preference. Please use my le�v� in �he
folfQwing m�nner:
R�n �3ut
Lurr�p Surr�
vacation
� L�, _ . ` VaGc��lOCI
sick f9aaters
�_��,�� �E�� 3 � ��Q�t��� r
�" �5c'��,o
�sflnus h�urs
f�Qnus �t�ws #�Y
I un�rstand t�r�t my pre�erer�ce ca�naf be changed or�ce this fe�rrn is sigr�ed and t�at my decisi[�n is
�
irrev#c��Ie.
�''' E�flPLCJ4'�E'S SiGNATURE:
✓
sac�a� sECUr�irY�: ;//
1L1[ TN��SES:
7
t � �
AQDRE55: �^
PHONE:
�ATE:
" t'� -1r.�
Revised 1142
�Q��, #ssao-�ac� Fsle Name: Employee Se�,ara#ion Pay Pref
1V7etr�ber Data
Nanie
�ate of �3irth
;°,ge at Retireirtent
i�i@I1e�C1aC'�' ����1
��3FT1G
I]�te of �3irfl�
,'��e at Re#irement
Retirem�nt D�ta
Hire Datc
Terminafion I�ate
E.ffectF�°e Date
FAC
Contrit�t.ti�ns
Interest
C'it�° �f' Clearwatear Emplayees' Reiirement S�rstem
�en�fii Estimate
RICHA�ZI] CRFAiti
12J3011991
U7fii2l2[i�3 �! �� ; •�,`,�d }`�
osraiiao�� " �
� 91,966.96
S C1.OU
$ O.QU
5ocial Security No.
SdCt&i S�CLiPI#� �U
Reiatianship :
� �F chi�dren under 1$ :
Calculation Typ.
Benefit Grou�
ketirement
fl,,r;�,,, i�IP rl >
For�nula for Benef�t A : 2.75% * 21.5056 yc�rs '` �91 E6�4��
Fr�r�n af I'ay�nent Fact�r
Nonnal Fc�nY7 ] .fl�Fi49
Single Life ��nnuiry I.OQF49
10 Year �ertain and Life tlnnuity 1.�[10[]0
;€)"-;, :1C?i[7t �ll1c� 5k3`:•�i�t�r
{i' ._:r,in,�3 J£7411�i ili�1C� :r�tld'[�f��EI:C
_ ir .�i1i114. r.i7.C� 54.11-t�'1L�i3i' .
� nE�
;.t..�,. - „�:. �� �-:� � � ..
1 �,I.i �n �i'�;I7: cr(.�l `�C3:4 �L'{.j1�
` xi�
� ���
�
�
W
Serviee
X��-X�C�
Estimste
Hazardous - Grandia#hered
1\"ormal Retirement
$�1.�� ��i °%n�
21 Years 6 1�7onihs 2 Uays
;4'�ar�thly Se�e£it
Pofen#ial
Tn Pviem6er To Bene�ci�ry
:��,561.8�i 'ivlA
�4,Sfi l .8 � NIA
�4,532.4b NIA
"`�'�?L ii:�L]11:5 (IlSp�1VLC{ iiI-[: 1L�. i��€�.titI'�lY3ti'C: j71.1?�3i]�E;a O11�V �li1C� 11YY�eS�' f:(;TtiIllilE11Ca1:2�Ci i}Zjl�i'.�`7Sc' SIl()l1�Ll C3tJf LlC il-L:a.t(;C� �i.S �11�31 F�:SLt�iS.
ThiS caicul�itas�n is su}�ject tc� corr�ct�on. If;,�ou are oa• becotn� ativare of errors in thc �iata that w�ac us�d; the ca�culatioi�s that ��ere
n3ade, ot• the �1�Ln prn��isinns thdt were an�lied, it is yotzr respoilsibility ta c�rn�act the }�1an ad�r�inistraEc�r. The �1a�� ha� the rig�lt to
recr�s�er fi•oin �•4u amo�nts that ��ere paid to ��au in error.
y:�'ssY'r.�:�*ir*�F�:'3rA•�k��-�;*9c�k3.�kici;r:fc'�'�11515 �nl�'`c��.G��1T17`dte }Ykk�r�x��*�;�:ic*ic�'s�icx�+:;F�9ck:kkA�;F9:ir
G�S Bene�t CalcuPatar� {C3"'29) - 1.:0.4+43. i J�6G (153y9} 1DX 29Cs 111!2� 13 Fi:S<:fl�F AM
CI7Y �3F CLEARWAT�R
P�N510�J �NTITLE1VkENT {)�'710h1 R�QUEST �ORM
k-kA�ARDOIJS DLJ�"Y EMPL{7YEE
1-�C,� d�.�J � G{2 L'x�.-�,i �a hRre�y� ��Ply tcr receive benefi�s r�nd�r th�:
City �f Ciearwater Gen�ral Em�lc�yees' Pensic�n PEan in accordance wsth the following
Date a� 8irkh: : Gender (circle onej:� F
Jab Cfassifica�ion: o � � �-� �����
Dep�rtment: o� c c.� ^17e��-.; �Q--
D�,t� af Nire: i z� 3c} • Gr
Senefits Ef�eeEi�re []ate � Yf ' r�
Divisi�n: %,
Dat� ofSeparation
� I'.�=Trz a �-
_� _
Spause s N�me:
Spc�use's Date ofi Birth: Sp�use's G�nder (circle on�}: f+Jl �
T�e type of pensian for which 1�m applying is (check only one}:
� Regular �'�nsion based �n years flf service
Job-can�ected Disability Pens€an
Nan-yob-connected f�isabifi#y F'ension
The Ci�jr o� Ciearv+!ater Err�ployees' Pension Plan proUides muitiple flptfons to Pian Par�ici�ants �s to the rn�nner ��
the pznsian ber�efst payrr�ent. C7pti�n 1 below represents th� stand�rd or narmal farrn of retirement benefif. l"he flther
opkional �orms [#k2- #7} shal! k�e carnputed tQ kre the Actu ariaf EquiWalent of the respective na�r��al bersefit.
Optican 7- Jflin# and Survivor Annuity
A�a annuity paid marsthly f�r the 1if� o� the Participar�t, �vith �'f0a% si.�n�ivar annu�ty paid mr�nthfy fc�r a period r�f fi+re
years folCawing the de�t� Qf the P�r�icip�nt tc� ihe beneficiary, provided th�t fr�llowing such fve ye�,r perio�l the survi�c��
annuity sha�l be rEduGed tc� 5fl°/o of the arigina] survivor annu'sty arnaunt. [See sectlors 2.397 {a] {3} {A}] Th�
'�articipant's sunrivir�g spouse receives th� de�ign�ted amc��nt �ar the rest of hislher life or untii helshe r�marries. ff
n�a survi�inc� spause, dependent children und�r the age af 18 sh�f1 be �eemed to be th� beneficiary �nd receiv�e the
�esignated amount until the age of 18. [5�ctiar� 2.397 �a} (3) and Section 2.398 (b} {1 }]
t7ption 2 � Li'fe Ar�nuity
�he Pariicipant receives f�islher pensian as 9ong as he.�she iives. Upon the death of t�e Partieip�nt, k�enefits c�as�.
�ection 2.41� [c} and 5ection 2.424 �b) (2) a. 1.]
��tior� 3-'10 Y�ar Certain &�ife Arinuit� -{must cfesignate a benef�ciary}
The Participant receiues hislher p�nsian as lang as hef$he lives. If the Pa�iicipant dies �efore 12D monthly payrnents
have been mad�, the rern�ining payments u� io the 12D paymerrts are made ta hislF�er E�errefECiary, pr the estate if
hislher beneiiciary is nat alive. [Sectir�ri 2.4Z4 (b} (2j a- Z-1
Qptian 4- 5€�°/o Jvit�t & 5urviWOr_Annui_ -{rnust desi�nate a benefi�iaryy
The Partici��nt r��eives his!her p�nsian as lor�g as h�Jsh� lives. If the Pa�tic]pa�nt dEes �rst, the ber,efGCiary r��eives
5p �ercen# af the pensiQn for t1�e rest oa the k�eneficiary'� Eife. If the heneficiary di�s first, the �'ariici�ant may elect
another benefciary or rnay coneinu� tcs rec�ive 14�J% Df hESlh�1` p�n5iD�1 and up�n hisJ}�er d�ath, ben�fFts cease.
�Se�tian 2.�t4 �k�) (2} a. 3.]
(3 tian 5- 75°I4 ,�aint c� S�rvi��r Annui -{m�ss# c�esignate a beneficiaryJ
The Par�'scipar�t r�eeives hislher p�nsion as lang a� n�Jsh� iives. If the P��ic�pdnt dies firsi, the b�neficiary r�ceiv�s
75 percent af thII pensian ��r t}�e rest of th� ��nefic�ary's life. !f the �encficia�;� dies first, the Particsparat may elect
ant�t�er b�neficiary c�r may cantinu� to �eceive 1�J(7°/� af hislher pensian and �par� hisfher cie�th, U�C�1E.'fIES CEc`iSP.
[Sec�ion 2.424 (�,1 f2} �. 3.1
.�
�
O tiern �- 90�°1Q Joint & 5€irvivor Ar�nui -{must des�gnat�e a beneficiaryj
I he Parti�ipa�,�t recei��es hisl�er �ensi�n �s long as h�i'she li��a. IF th� Particip�nt dies first, th� 't7�nesici�iy receives
1G�' perc�:��t of thu ppnsion for tf�e rest af the �enefi�i�ry'� I�fe. If th� b�n2ficiary dies firs;. ta�e Partic?pant may �Ivc�
ar�oth�r ben�*i�ian,� ar may can�inue to r�ceive 1Q0�/� of hislhe� pension and u�on hislher d�ath, be��efits ceas�
[�eetian 2.42� ��;i j2} a. 3.�
Q tion 7-- 6E a13°/a Joinf $� Survi�or Annui -{must designate a beneficiaryy
Th� Participant rec�i�res hislher per�siar� as long as hels;�e liv�s. If the Participant dies ;irs�, the benefi�;i�ry receives
6� zi., percer�t Q� t:-Ee pension for the rest aT �he benefciary's life. !f thz b�n�ficrary dies fsrst, �1�e PartE�ipani may el�ct
a�sather b�ne�cia�y ar may continue to receie�e '€Df]°o of hisJher pensir�n and upon hisJh�r death, ben�fts ce�se.
[Section 2.424 f �1 (2} a. 3.�
PartiaE LuEn 5um Pa ment O tir�n
A partial lump su�n payrnent eqs�al t� �ither ten p�rcent �1[]�/a}, twenty percer�t �2C1°Ia}, or tY�irty percent l30°/0) o'f khe
actuarially determined valu� of the n�rmal retirement benef'rt due the member may �e eGected in c�mbination with any
o� the c�ptfons indicated ak�ave. If a+nember elects sueh a par�ial lurr�p sum distributir�n; tf�en the r;�or�thly r�tir�rnent
benefit far ihe optic�n s�lected sh�fi be recfuced aecordingly therea�ter. [5ection �.�2� (�} �2) a. 4.]
I have considered the uarious bene€it paym�:rrt m�thods under suc1� Plan and have elected t� receiUe my r�tir�ment
benefits as indieated belaw. {Note: C]ption selectiQr, to b� indicated both �y Number ar�d C]escripiion.)
l ur�de�t?n� th�� �n�e my fiirst perasian check is receiv�d, my de�isian an tf�is vption is irre�ocat�ke-
If takin� Qption 7 sign belov�r:
�ption #: 'C crip i: Joint and Survivar Annui
Employee's 5ignature: ':; __ Date: � "� ''` -�
��pendenf chiCdren under t�e c�f 18 and residing 9r� my household are:
Chi��`� rt�af,-°A Gender C]ate of Birth
� �
� �
If #akin (}
a�t��� #: �
�
�
2 si n k�elovtt 2- ^
❑escrip#inn: Life Annu
ployee'5 Signature
�iakin Opi
�fion #: 3
fill i�s b�:neficiary information and sign below:
My designated be�eficiary is
h�arne�
�]ate af Bi�h:
f�ddre�s;
Phone Nurnb�r:
Emplave�'s Sic�natur�:
�ate:
❑escription 1,� YEar Ger�ain and Lif_e_Annuity
Social Security Num�er. ---
Gender �Circle �ne} M �
[�afie:
lfi t�kin� Optiort 4, 5, 6,Qr 7, #ili in Dptian Number, �escription and_berseFici�ry i�forn�atfor� anci s9gr� �elow:
C)ption �' __� �es�r=pti�:� _ "i� Jaint and S.irv�var An�uit�,� ._
M�,� designa��d bene�yciary is:
Narn�:
Date of Birth:
Addrass:
Phone Numb�r:
�mploye�'s Signatu�e:
ff #akin a Partial L�am
C�ptian #: NA
SQCiai S�curity� EVu��o�r.
Gender ��ircfe �ne} M F
[]ate:
Surri Pa rnent, fill in F'ercenta e and si n b�low:
Descriptian: P�rtia! Lump 5um Payrnent _
f elect t� take a par�ial lump sum payrnent sn ihe fa�9owing amount (check only one}:
10°!0 of the actu�r�ally determin�d �aBu� af the normal retirement benefit
2�"I� �f fhe actuarially d�i�rrr,ined value af the nc�rm�l retirement benefit
30°,0 of the actu�riafly determir�ec� valu� of the nc�rrna! reiirernent benefFt
I+�nderstand my monthly retirement benefit fQr �h� optic�n selec#ed �bove shal] �e reduced accdrdtngly.
Em�lovee's Siqnature:
If naming a beneficiary ONLY, fill in bene#ic
My d�signaiec! beneficiary is:
Bene�ciary �arr�e:
Ben�fciary �ate of Birth: _
B�neficiary Address:
8er�e�ciary Phane iJumb�r:
�rnPloye�'s Signature: —
�
�TATE �7F �LD�IDA
CLL7NTY' C]F
PIiV��LAS
Rev. ���`13
Form #99G0_r?�J�J�
C]ate:
inforrnatiQn and sign below:
N Beneficiary Sc�cial Security #:
Benefici�ry �ende�' {Circ�e C7ne) M F
Date:
The �aregoing instru�n�n� was acknotivledge� E�efar� rne #his
��� day of �_�Cc.�� _ , 2C�%,�
�y ��:��r� ���CL3! _.
wha is personally knowr� to me or wha has prowi�ded _ �^
as identificatior� and vti+ho did,�did t�c�t tak� an o�th.
i�otary �'ublic
� t ,a����o.w��,
/�II� ��'�; �� �,����, Name of �Jc�tary Prini�d
My Cammissior� expires: ���� .��'n
�
� nniG����.� �uic�
�o�r�r Pus�.�c
STATE oF FLC]f�#CiA
m �04TI1T:� ����}'��Q�
�xpires �f23J2D i f
File Name: P�nsion Entitlem�nt C3p:ian Form
Pension Trustees Agenda
Council Chambers — City Hall
Meeting Date:8/12/2013
SUBJECT / RECOMMENDATION:
Approve the request of employee James Geary of tbe Customer Service Department to vest his pension as provided by Section 2.419 of
the Employees' Pension Plan.
SUMMARY:
James Geary, Director, Customer Service Department, was employed by the City on September 14, 1998, and began participating in
the Pension Plan on that date. Mr. Geary terminated from City employment on October 29, 2012.
The Employees' Pension Plan provides that should an employee cease to be an employee of the Ciry of Clearwater or change status
from full—time to part—time after completing ten oanore years of creditable service (pension participation), such employee shall acquire
a vested interest in the retirement benefits. Vested pension payments commence on the first of the month following the month in which
the employee normally would have been eligible for retirement.
Section 2.416 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 reacbed 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. Mr. Geary meets the non�azardous duty criteria.
Review Approval:
Cover Memo
Item # 4
APP�ICATIC7I� FdR VESi'EQ REGHTS PEhlSI{7N
��„��� i� .�����' being a persor� k���i�� empfoyment witf� �he
Gity c�f Clearvvater, Flarid�, and havir�g completed te� �1a} ar mare years af credited service,
�ch service having occurred du�ing the period from �dat� r�f entry inic� Pensian Pfan}
� c-�yr�' ta (date af resignatic�n ar �ha�ge of �tatus� . �c: -z'�- r� �n,�
here�y m�ke� a�plicatit�n t� receive the vested rights p�r�sion provided far by the Gi�y Code c��
Qrdinances. �4s such farmer emplpyee, l unde�stand �1�e �ensiorr requested vvill be c�mputed
pursuant tc� ��e prgvis�or�s of �he City Cod� of flrdinance in e�ect on �he date of �esigr��t�ar�.
� here�y further certify t�at my dat� of birth is � 3- �''� � ���
The date I will begin t� recei�re my pensian will be �? 3-- �-- ��' d�
Further, I additiflnally ceriify that f have rnade r�c� application seeking ta c�k�t�in a return af th�
c�ntributions that I paid irr�t� t�e Per�sion Fund during the period of my emp�oyment set forth
abc��e, I have not been convicted of a felany during my peri�d of empioyment, and I have not
r�cei�reu a; ;� :�±h�'r tYp� of pensic��? fr�m t�e �i�v.
��� �
Sigr�� �e Social Security 1Vumber
��partmentl��vision
Jo� Classification
�"I :i� l� s A�1 1� b�
5treet Addre�s
r
��i�� �-�A�,�:� �� � � `��'�" � - �i o�
F City, State, Zip �c�de
STATE QF �L[�RICrA The fc�regoirtg i�strument was acknowledg�:d befare
C�UNTY i�F PINELLAS me this '`� day �f drJ� ,� ,�U I�
� by � n�'Y�,� ��r� d�
�
� wha 3s p�rsor�alfy known tcr m� or wi�c� has prflvided
MlCW�ltE KUTGF4
ND'�AfiY PllBLIG
z STATE +DF �L�R��iA
� �a�mri+#�E20i50f
F.xpires 512312[li 6
_.�_..-�----.--�
and who �idfdid �o� take an �ath.
a5 identification
� C-�'�1��`� �E� � pta ty �' U�Y � I C
� ���'�v��- ��� _ �lame of f�atary Printed
My ��mmi�sion �expir�s: � � �
Rev. �l09 Vested F'ension Form