Enclosed you will find an application for retirement or disability benefits. Please complete all the information requested and sign the application.

Transcription

1 Dear Applicant: Enclosed you will find an application for retirement or disability benefits. Please complete all the information requested and sign the application. Please submit a legible copy of one proof of age in accordance with the attached sheet of instructions. If you are married, you will also need to submit a copy of proof of age for your spouse and proof of your marriage license. If you are applying for disability benefits, you need to attach a copy of the document whereby you were awarded disability benefits from the Social Security Administration Office or other evidence of disability. In the event this document is not yet available be sure to submit your application to avoid any delay in the effective date of your benefits. The normal process of a retirement application may take between 45 and 90 days. In order to hasten this process, you should submit your completed and signed application package, plus the applicable copies of your supporting documents to: IUOE You may contact the Pension Department with your questions or concerns by calling (877)

2 INSTUCTIONS FOR PROVIDING PROOF OF AGE At the time of your application for benefits, you and your spouse are required to produce proof of age. The following is a list of the documents, which may serve as proof of your age. Some of these documents are better proof than others. This list is arranged starting with the best type of proof and descending to the least desirable type of proof document. You are required to furnish the best type of proof that is available. It is recognized, of course, that in many cases, a birth certificate will not be available, particularly for those who were born outside the United States. In that case, you should secure the next best type of proof. Do not submit the original of any of these documents; you may submit ONE legible photocopy of the following for each (you and spouse): A Birth Certificate. A Baptismal Certificate or Statement as to the date of Birth shown by Church records, certified by the custodian of records. Notification of Registration of birth in a public registry of vital statistics. Hospital Birth Record certified by the custodian of such records. A Foreign church or government record. A signed statement by the physician or midwife who attended the birth, as to the date of birth shown on their records. Immigration Papers such as Passport, Alien Card, etc. Military Records. School Records, certified by the custodian of such records. Marriage Records showing date of birth or age (Application for Marriage License or Church Record, certified by the custodian of such records, or marriage certificate). An Insurance Policy which shows the age or date of birth. Other evidence, such as signed statements from persons who have knowledge of the date of birth, voting records, poll tax receipts, Driver s License, etc. 2

3 APPLICATION FOR PENSION BENEFITS MEMBERS INFORMATION COMPLETE THIS FORM IN INK AND RETURN WITH THE REQUIRED DOCUMENTS NAME OF APPLICANT: SOCIAL SECURITY NUMBER: ADDRESS: TELEPHONE NUMBER: BIRTH DATE: (Attach Certificate of Birth) TYPE OF RETIREMENT: Normal Early Disability Vested Late Pro-rata DATE OF RETIREMENT LAST DAY WORKED INITIATION IN LOCAL NAME OF EMPLOYER NAME OF LAST LOCAL 487 EMPLOYER SPOUSE DATA MARITAL STATUS: Never Been Married Married (Attach Certificate of Marriage) Divorced (Attach Divorce Decree) Widowed (Attach Certificate of Death) If you are divorced, is there a Qualified Domestic Relations Order (QDRO) in place or pending? Yes No NAME OF SPOUSE SPOUSE S DATE OF BIRTH SPOUSE S SSN: (Attach Certificate of Birth) 3

4 BENEFICIARY INFORMATION (If no spouse) NAME: RELATIONSHIP: ADDRESS: TELEPHONE NUMBER: DATE OF BIRTH: SOCIAL SECURITY NUMBER: LIST BELOW PERIOD OF INTERRUPTION IN YOUR EMPLOYMENT DUE TO DISABILITY, MILITARY SERVICE, MATERNITY/PATERNITY LEAVE OR WORK FOR A SIGNATORY EMPLOYEE IN NON- COVERED EMPLOYMENT. REASON FOR INTERRUPTION FROM (Month/Year) TO (Month/Year) IF DISABILITY RETIREMENT, *HAVE YOU APPLIED FOR BENEFITS FROM THE SOCIAL SECURITY? Yes No * LIST CAUSE AND NATURE OF DISABILITY: ARE YOU NOW OR WERE YOU EVER A SOLE PROPRIETOR, PARTNER OR SOLE SHAREHOLDER OF A COMPANY IN THIS TRADE? Yes No IF YES, EXPLAIN AND SUPPLY DATES: I HEREBY CERTIFY TO THE BOARD OF TRUSTEES THE ABOVE STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE. I ALSO CERTIFY THAT IF I AM MARRIED TODAY OR IF I WAS MARRIED DURING THE PRIOR TWELVE (12) MONTHS, MY SPOUSE S NAME AND INFORMATION IS LISTED ABOVE. I UNDERSTAND A FALSE STATEMENT MAY DISQUALIFY ME FOR BENEFITS. THIS APPLICATION REVOKES ANY PRIOR APPLICATION OR BENEFICIARY DESIGNATIONS. APPLICANT S SIGNATURE DATE NOTARY (SEAL) DATE 4

5 RETIREMENT DECLARATION I declare that, as a result of my retirement, I have separated from service with all employment in the industry on the date stated below, and that I have not been engaged in any employment in the industry since that date. I also declare that I am no longer actively involved in the day-today affairs of any business in the industry in which I have or have had an ownership interest. You will not be considered retired if you work more than 40 hours per month: in the same industry; and in the same trade or craft; and in the State of Florida or in any other geographic area covered by the plan. I have read and understand the attached SUMMARY OF THE PLAN PROVISIONS ON SUSPENSION OF BENEFITS DUE TO A RETURN TO WORK, in accordance with the provisions of the plan. I understand that if after I retire and begin receiving benefits from the plan, and return to work and are paid for any work described above, you must notify the Trustees within 30 days after you start work. You will be required to give up your pension for months during which you were employed more than 40 hours. When you retire again, you must notify the Trustees so that your pension benefits may resume. I further acknowledge that failure to provide written notice within 30 days upon my employment I will be obligated to repay to the fund all such erroneously months received after returning to work. The full amount of the pension payments must be reimbursed to the plan. The amount of such payments, up to three months will be deducted from the benefits due after you stop working. If more than three months is owed the plan, the maximum amount that may be deducted from each monthly payment after the initial three months will not be more than 25% of the monthly amount paid which should have been suspended. If you die before all of the overpayments have been reimbursed to the plan, deductions will be made from the benefits to your spouse or beneficiary, with the 25% limitations per each benefit payment. NAME SOCIAL SECURITY NUMBER LAST DAY WORKED IN INDUSTRY SIGNATURE 5