Pension Entitlement Option Form Hazardous Duty Beneficiary Only

CITY OF CLEARWATER
PENSION ENTITLEMENT OPTION REQUEST FORM
HAZARDOUS DUTY EMPLOYEE
I,
do hereby apply to receive benefits under the
(Please print name)
City of Clearwater General Employees’ Pension Plan in accordance with the following:
Employee ID #
Date of Birth:
Job Classification:
Department:
Gender (circle one):
M
F
Division:
The City of Clearwater Employees’ Pension Plan provides multiple options to Plan Participants as to the manner of
the pension benefit payment. Option 1 below represents the standard or normal form of retirement benefit. The
other optional forms (#2- #7) shall be computed to be the Actuarial Equivalent of the respective normal benefit.
Option 1 - Joint and Survivor Annuity
An annuity paid monthly for the life of the Participant, with a 100% survivor annuity paid monthly for a period of five
years following the death of the Participant to the beneficiary, provided that following such five year period the
survivor annuity shall be reduced to 50% of the original survivor annuity amount. [See section 2.397 (a) (3) (A)] The
Participant’s surviving spouse receives the designated amount for the rest of his/her life or until he/she remarries. If
no surviving spouse, dependent children under the age of 18 shall be deemed to be the beneficiary and receive the
designated amount until the age of 18. [Section 2.397 (a) (3) and Section 2.398 (b) (1)]
Option 2 – Life Annuity
The Participant receives his/her pension as long as he/she lives. Upon the death of the Participant, benefits cease.
[Section 2.416 (c) and Section 2.424 (b) (2) a. 1.]
Option 3 - 10 Year Certain & Life Annuity - (must designate a beneficiary)
The Participant receives his/her pension as long as he/she lives. If the Participant dies before 120 monthly
payments have been made, the remaining payments up to the 120 payments are made to his/her beneficiary, or the
estate if his/her beneficiary is not alive. [Section 2.424 (b) (2) a. 2.]
Option 4 - 50% Joint & Survivor Annuity - (must designate a beneficiary)
The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives
50 percent of the pension for the rest of the beneficiary’s life. If the beneficiary dies first, the Participant may elect
another beneficiary or may continue to receive 100% of his/her pension and upon his/her death, benefits cease.
[Section 2.424 (b) (2) a. 3.]
Option 5 - 75% Joint & Survivor Annuity - (must designate a beneficiary)
The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives
75 percent of the pension for the rest of the beneficiary’s life. If the beneficiary dies first, the Participant may elect
another beneficiary or may continue to receive 100% of his/her pension and upon his/her death, benefits cease.
[Section 2.424 (b) (2) a. 3.]
Option 6 - 100% Joint & Survivor Annuity - (must designate a beneficiary)
The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives
100 percent of the pension for the rest of the beneficiary’s life. If the beneficiary dies first, the Participant may elect
another beneficiary or may continue to receive 100% of his/her pension and upon his/her death, benefits cease.
[Section 2.424 (b) (2) a. 3.]
Option 7 – 66 ⅔% Joint & Survivor Annuity - (must designate a beneficiary)
The Participant receives his/her pension as long as he/she lives. If the Participant dies first, the beneficiary receives
66 ⅔ percent of the pension for the rest of the beneficiary’s life. If the beneficiary dies first, the Participant may elect
another beneficiary or may continue to receive 100% of his/her pension and upon his/her death, benefits cease.
[Section 2.424 (b) (2) a. 3.]
Partial Lump Sum Payment Option
A partial lump sum payment equal to either ten percent (10%), twenty percent (20%), or thirty percent (30%) of the
actuarially determined value of the normal retirement benefit due the member may be elected in combination with
any of the options indicated above. If a member elects such a partial lump sum distribution, then the monthly
retirement benefit for the option selected shall be reduced accordingly thereafter. [Section 2.424 (b) (2) a. 4.]
I have considered the various benefit payment methods under such Plan and have elected to receive my retirement
benefits as indicated below. (Note: Option selection to be indicated both by Number and Description.)
I understand that once my first pension check is received, my decision on this option is irrevocable.
If taking Option 1 sign below:
Option #: 1
Description:
Joint and Survivor Annuity
Employee’s Signature:
Date:
Dependent children under the age of 18 and residing in my household are:
Child’s Name
If taking Option 2 sign below:
Option #: 2
Description:
Gender (M-F)
Date of Birth
Social Security #
Life Annuity
Employee’s Signature:
Date:
If taking Option 3, fill in beneficiary information and sign below:
Option #: 3
Description:
10 Year Certain and Life Annuity
My designated beneficiary is:
Name:
Social Security Number:
Date of Birth:
Gender (Circle One)
M
F
Address:
Phone Number:
Employee’s Signature:
Relationship
Date:
If taking Option 4, 5, 6,or 7, fill in Option Number, Description and beneficiary information and sign below:
Option #:
Description:
% Joint and Survivor Annuity
My designated beneficiary is:
Name:
Social Security Number:
Date of Birth:
Gender (Circle One)
M
F
Address:
Phone Number:
Relationship
Employee’s Signature:
Date:
If taking a Partial Lump Sum Payment, fill in Percentage and sign below:
Option #:
NA
Description:
Partial Lump Sum Payment
I elect to take a partial lump sum payment in the following amount (check only one):
10% of the actuarially determined value of the normal retirement benefit
20% of the actuarially determined value of the normal retirement benefit
30% of the actuarially determined value of the normal retirement benefit
I understand my monthly retirement benefit for the option selected above shall be reduced accordingly.
Employee’s Signature:
Date:
If naming a beneficiary ONLY, fill in beneficiary information and sign below:
My designated beneficiary is:
Beneficiary Name:
Beneficiary Social Security #:
Beneficiary Date of Birth:
Beneficiary Gender (Circle One)
M
F
Beneficiary Address:
Beneficiary Phone Number:
Relationship
Employee’s Signature:
STATE OF FLORIDA
COUNTY OF
PINELLAS
Date:
The foregoing instrument was acknowledged before me this
day of
, 20__
by
who is personally known to me or who has provided
as identification and who did/did not take an oath.
(Signature)
Notary Public
Name of Notary Printed
My Commission expires:
Rev. 04/13
Form #9900-0009
File Name: Pension Entitlement Option Form