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APPLICATION FOR RETIREMENT PENSION BENEFIT

By Philip Morales,2014-06-28 20:39
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APPLICATION FOR RETIREMENT PENSION BENEFIT ...

     CENTRAL STATES

     SOUTHEAST AND

     SOUTHWEST AREAS

     PENSION FUND

    APPLICATION FOR RETIREMENT PENSION BENEFIT

Dear Participant:

This Application for Retirement Pension Benefit packet is made up of the following

    forms all of which must be completed and forwarded to the address shown below

    before you can be approved for a retirement pension benefit from the Pension Fund:

     Pension Application Form/Background Information/Employment History

     Please be sure to enclose copies of all appropriate documents

    (such as proof of age, marriage certificate, divorce decree, etc.).

     Tax Withholding Form

     Benefit Payment Method Form

     Payment Options

     Please do not complete the JSO Election or JSO Waiver more than

    180 days before your retirement date S if you do, they cannot be

    accepted.

     Retirement Declaration Form

We recommend that you complete the above forms and return them to us at least 90

    days (but not more than 180 days), before your retirement date. By doing so, you will

    allow us the opportunity to review your eligibility status in advance and help us provide

    you with your first benefit check as close to your retirement date as possible.

All forms and documents should be submitted to the following address:

    Central States, Southeast and Southwest Areas Pension Fund

    PO Box 5109

    Des Plaines, IL 60017-5109

    If you have any questions, please call us toll-free at 1-800-323-5000.

PO Box 5109

    Des Plaines, Illinois 60017-5109 www.centralstates.org

    Phone: (800) 323-5000

     C:\convert\temp\61767546.doc 10/12/2009 1

    PENSION APPLICATION FORM/

    BACKGROUND INFORMATION/EMPLOYMENT HISTORY

    PRINT OR TYPE ALL INFORMATION PARTICIPANT’S SOCIAL SECURITY NO. LAST NAME IF FEMALE, MAIDEN NAME FIRST NAME MIDDLE GENDER INITIAL MALE FEMALE STREET ADDRESS ZIP CODE CITY STATE HOME PHONE NUMBER (incl. Area Code)

     E-MAIL ADDRESS

    MILITARY SERVICE (MONTH / YEAR) DATE MONTH / DAY / YEAR RETIREMENT MONTH / DAY / YEAR OF DATE BIRTH FROM TO MARITAL STATUS SPOUSE’S LAST NAME FIRST NAME MIDDLE IF FEMALE, MAIDEN NAME MARRIED SINGLE WIDOWED DIVORCED INITIAL

    SPOUSE’S SOCIAL SECURITY NO. SPOUSE’S MONTH / DAY / YEAR DATE MONTH / DAY / YEAR DATE OF OF BIRTH MARRIAGE

LIST CHILDREN’S COMPLETE INFORMATION

    BIRTHDAY NAME ADDRESS (City, State, ZIP Code) RELATIONSHIP MONTH / DAY / YEAR

LIST COVERAGE UNDER ANY OTHER TEAMSTER

    PENSION FUND AND/OR COMPANY PENSION PLAN

    PERIOD OF COVERAGE NAME OF FUND / COMPANY PLAN CITY AND STATE FROM / TO DATES (MONTH / YEAR)

PLEASE INCLUDE COPIES OF THE FOLLOWING DOCUMENTATION WITH THIS APPLICATION AND MAIL IT TO THE ADDRESS SHOWN

    ON PAGE 4 [DO NOT SEND ORIGINAL DOCUMENTS]:

     YOUR BIRTH CERTIFICATE (OR OTHER PROOF OF AGE)

     SPOUSE’S BIRTH CERTIFICATE (OR OTHER PROOF OF AGE)

     MARRIAGE CERTIFICATE

     DIVORCE DECREE

PLEASE NOTE THAT IF YOU DO NOT PROVIDE THE FUND WITH TIMELY NOTICE OF YOUR RETIREMENT, ANY RETROACTIVE

    BENEFIT PAYMENTS THAT YOU WOULD OTHERWISE BE ELIGIBLE TO RECEIVE ARE LIMITED TO THE 12-MONTH PERIOD PRIOR TO

    THE DATE THE FUND RECEIVES WRITTEN NOTIFICATION OF YOUR RETIREMENT DATE.

     2

LIST ALL EMPLOYMENT, REGARDLESS OF WHETHER IT PROVIDED FOR PARTICIPATION IN CENTRAL STATES PENSION FUND, BEGINNING WITH YOUR PRESENT OR MOST RECENT EMPLOYER. ADD ADDITIONAL PAGES FOR EMPLOYMENT HISTORY IF NEEDED.

    PERIOD OF LOCAL UNION # EMPLOYMENT AT TIME OF NAME OF EMPLOYER ADDRESS OF EMPLOYER FROM / TO EMPLOYMENT EMPLOYER ADDRESS FROM/TO (MONTH/YEAR) LOCAL UNION #

     CITY, STATE & ZIP

    TYPE OF WORK (BE SPECIFIC)

    COMPANY OUT OF BUSINESS? REASON FOR LEAVING YES NO

    WORK COVERED BY TEAMSTER CONTRACT REQUIRING CONTRIBUTIONS TO CENTRAL STATES PENSION FUND? YES NO

    EMPLOYER ADDRESS FROM/TO (MONTH/YEAR) LOCAL UNION #

    CITY, STATE & ZIP

    TYPE OF WORK (BE SPECIFIC)

    COMPANY OUT OF BUSINESS? REASON FOR LEAVING YES NO

    WORK COVERED BY TEAMSTER CONTRACT REQUIRING CONTRIBUTIONS TO CENTRAL STATES PENSION FUND? YES NO

    EMPLOYER ADDRESS FROM/TO (MONTH/YEAR) LOCAL UNION #

     CITY, STATE & ZIP

    TYPE OF WORK (BE SPECIFIC)

    COMPANY OUT OF BUSINESS? REASON FOR LEAVING YES NO

    WORK COVERED BY TEAMSTER CONTRACT REQUIRING CONTRIBUTIONS TO CENTRAL STATES PENSION FUND? YES NO

    EMPLOYER ADDRESS FROM/TO (MONTH/YEAR) LOCAL UNION #

     CITY, STATE & ZIP

    TYPE OF WORK (BE SPECIFIC)

    COMPANY OUT OF BUSINESS? REASON FOR LEAVING YES NO

    WORK COVERED BY TEAMSTER CONTRACT REQUIRING CONTRIBUTIONS TO CENTRAL STATES PENSION FUND? YES NO

HAVE YOU EVER WORKED IN ANY OF THE FOLLOWING CAPACITIES WHILE A PARTICIPANT OF CENTRAL STATES PENSION FUND? Manager/Supervisor Self-employment Owner/Operator OR Had significant ownership (50% or more) in the company? If yes, complete the following:

    PERIOD OF EMPLOYMENT DID YOU HAVE THE RIGHT TO HIRE, COMPANY NAME SITUATION (SEE ABOVE) FIRE, OR RECOMMEND IT? FROM / TO (MONTH / YEAR) (CHECK ONE)

     YES NO

     YES NO

     3

    OATH AND SIGNATURE

I am applying for a pension benefit from Central States, Southeast and Southwest Areas Pension Fund. Under

    penalty of perjury, I certify that the information I have given in this application is true and correct to the best of my

    knowledge.

    APPLICANT'S SIGNATURE DATE

IMPORTANT INFORMATION REGARDING YOUR BENEFITS AND THE PENSION PROTECTION ACT

On March 24, 2008, the Pension Fund's actuary certified that the Pension Fund is in

    critical status under the Pension Protection Act (PPA), and notice of this fact was given

    to all participants on April 8, 2008. With respect to plans in critical status, the PPA

    creates a category of “adjustable benefits,” which generally includes all benefits other

    than a contribution based pension payable at age 65; these benefits may be eliminated

    or reduced in the future (even for participants that have retired and already begun

    receiving their pensions), largely depending on whether the participant’s employer (or

    former employer) continues to participate in the Pension Fund and agrees to a

    contribution schedule sufficient to maintain current benefits. Although the Pension Fund

    anticipates that the vast majority of bargaining units will elect a contribution schedule

    that keeps current benefits in place, because of the possibility of a reduction or

    elimination in benefits, you should weigh your decision to retire with care. In addition,

    under the PPA, the Pension Fund cannot guarantee that it will never be required to

    change its existing rules concerning adjustable benefits. However, in the event your

    adjustable benefits are reduced or eliminated in the future, you will receive a separate

    notice at least 30 days prior to the effect of any such benefit reduction.

    RETURN TO: CENTRAL STATES, SOUTHEAST AND SOUTHWEST

    AREAS PENSION FUND

    P.O. BOX 5109

    DES PLAINES, IL 60017-5109

     4

    TAX WITHHOLDING FORM

Note: Form W-4P is for U.S. citizens, resident aliens, or their estates who are recipients of

    pensions, annuities (including commercial annuities), and certain other deferred compensation.

    Use Form W-4P to tell payers the correct amount of federal income tax to withhold from your

    payment(s). You also may use Form W-4P to choose (a) not to have any income tax withheld

    from the payment (except for eligible rollover distributions, or payments to U.S. citizens delivered

    outside the United States or its possessions) or (b) to have an additional amount of tax withheld.

You may use the Pension Benefit Tax Withholding calculator on our website at

    www.centralstates.org to assist you in determining your tax withholding. If you have any questions, please consult your tax professional, or obtain a complete Form W-4P from the IRS for

    additional worksheets and instructions.

If you wish to make a tax election, please complete Form W-4P below.

     FormW-4P Withholding Certificate for OMB No. 1545-0415 Department of the Treasury Internal Revenue Service Pension or Annuity Payments

    Type or print your full name Your social security number

    Home address (number and street or rural route) Claim or identification number (if any) of your pension or annuity contract City or town, state, and ZIP code

     N/A

    Complete the following applicable lines: 1 Check here if you do not want any federal income tax withheld from your pension or annuity. (Do not complete lines 2 or 3.) . . ?

    2 Total number of allowances and marital status you are claiming for withholding from each periodic pension or annuity payment. (You may also designate an additional dollar amount on line 3.) . . . . . . . . . . . . . . . . . . ? (Enter number Marital status: Single Married Married, but withhold at higher “Single” rate of allowances) 3 Additional amount, if any, you want withheld from each pension or annuity payment. (Note. For periodic payments, ? $ you cannot enter an amount here without entering the number (including zero) of allowances on line 2.) . . . . . . . . . (No pennies)

     Your Signature ? Date ?

If you are a nonresident alien and do not have a Social Security Number you may not use Form

    W-4P. Please write us at Central States Pension Fund, PO Box 5113, Des Plaines, IL 60017-5113 if this applies to you.

     5

    ***INSTRUCTIONS FOR COMPLETING FORM W-4P***

TO ELECT NOT TO HAVE FEDERAL TAXES WITHHELD FROM YOUR PENSION

    BENEFIT:

    1. PRINT YOUR NAME, ADDRESS AND SOCIAL SECURITY NUMBER

    IN THE SPACE PROVIDED.

    2. CHECK THE BOX IN LINE 1.

    3. SIGN AND DATE THE ELECTION AND RETURN TO CENTRAL

    STATES.

TO ELECT TO HAVE FEDERAL TAXES WITHHELD FROM YOUR PENSION

    BENEFIT (BASED ON IRS TAX TABLES):

    1. PRINT YOUR NAME, ADDRESS AND SOCIAL SECURITY NUMBER

    IN THE SPACE PROVIDED.

    2. CHECK ONE OF THE MARITAL STATUS OPTIONS AND COMPLETE

    THE NUMBER OF ALLOWANCES SECTION IN LINE 2.

    3. YOU CAN DESIGNATE TO HAVE AN AMOUNT WITHHELD, IN

    ADDITION TO THE TAX TABLE AMOUNT, ON LINE 3.

    4. SIGN AND DATE THE ELECTION AND RETURN TO CENTRAL

    STATES.

    ***Please note that the IRS does not allow for a specific ("flat") amount to be withheld. Therefore, tax withholding must be based on your marital status and number

    of allowances plus any additional amounts you wish to have withheld. If you need

    additional assistance or have any questions regarding Form W-4P, please consult your

    tax professional or see IRS Form W-4P for complete withholding instructions on

    pensions.

     5a

    ------This Form Is Required To Initiate Your Pension Benefit Payments------

    BENEFIT PAYMENT METHOD FORM

You can avoid worrying about when you will receive your pension check by using the Fund’s Electronic Funds Transfer (EFT) program.

    Under the EFT program your pension check is deposited electronically and automatically into your checking or savings account on the first day of each month (unless the first day of the month falls on a weekend or a banking holiday). IF YOU ARE ELIGIBLE FOR RETIREMENT BENEFITS, YOUR FIRST ONE OR TWO PENSION CHECKS WILL BE SENT TO YOUR MAILING ADDRESS AND

    SUBSEQUENT PAYMENTS WILL BE DEPOSITED ELECTRONICALLY INTO YOUR CHECKING OR SAVINGS ACCOUNT.

     I hereby authorize the Central States, Southeast and Southwest Areas Pension Fund, and the financial institution shown

    below, to deposit my pension benefit directly into my account each month. If funds to which I am not entitled are deposited

    into my account, I/we authorize the Fund to direct the bank to return those funds and to provide any and all information in

    their records which may assist the Fund in the recovery of those funds including but not limited to the identity of all account

    holders. This authorization will remain in effect until I file a new authorization form or cancel my participation. Signature: Date: Social Security Number: Home Telephone Number: Home Address: City: State: Zip Code: Bank Name: Bank Address: City: State: Zip Code: Type of Account: Checking Savings

    Routing Number: * Account Number: IMPORTANT: In the space below attach a voided check or pre-printed savings deposit slip with the correct bank routing and transit

    numbers.

    ATTACH VOIDED CHECK OR DEPOSIT SLIP HERE

    *9 DIGIT CODE IN THE LOWER LEFT CORNER OF CHECK OR DEPOSIT SLIP THAT STARTS WITH 0, 1, 2 OR 3

     I do not want electronic funds transfer and elect instead to have my benefit check sent to my mailing address each month. I

    understand that my benefit checks will be mailed on the first day of each month and that my check may be delayed for

    reasons beyond the Fund’s control and that there is no guaranteed delivery date. I further understand that in the event a thcheck is lost the Fund cannot issue a replacement check until the 10 business day of the month.

    Signature: Date: Social Security Number:

    IMPORTANT: You must keep the Fund informed of any change in your address, regardless of which

    payment method you choose.

     6

    PAYMENT OPTIONS

If you are single when you retire, your benefit will be paid as a single life annuity under the

    Lifetime Only Option or the Lifetime with Limited Surviving Spouse Option, depending on the

    Benefit Class you were at when you retired.

If you are married when you retire, the normal form of payment is the Joint and 50% Surviving

    Spouse Option. The Joint and 50% Surviving Spouse Option provides for a reduced monthly

    payment for your lifetime so that in the event you die before your spouse, 50% of your reduced

    monthly benefit will continue to your spouse for the remainder of his or her lifetime.

For those pension benefits effective on or after March 1, 2008, the Fund now offers an optional

    Joint and 75% Surviving Spouse Option form of payment. However, you will receive your

    retirement benefit in the form of the Joint and 50% Surviving Spouse Option unless you

    affirmatively elect the Joint and 75% Surviving Spouse Option or waive both Joint and Surviving

    Spouse Options. If you choose to waive both Joint and Surviving Spouse Options, we will

    require your spouse’s written, notarized consent as explained in the attached forms.

    Attached are the following forms, one of which must be completed and returned to Central States, Southeast and Southwest Areas Pension Fund, at the address below, before your

    retirement benefit can be paid. No form, Election or Waiver, that is signed more than 180 days

    prior to your retirement date will be accepted.

     ELECTION OF JOINT AND SURVIVING SPOUSE OPTION

     WAIVER OF JOINT AND SURVIVING SPOUSE OPTION

     (Including notarized spouse consent)

    Central States, Southeast and Southwest Areas Pension Fund

    P.O. Box 5109

    Des Plaines, IL 60017-5109

    If you have any questions, please call us at 1-800-323-5000.

     7

    ELECTION OF JOINT AND SURVIVING SPOUSE OPTION ("JSO PENSION")

    Participant: Name: Birth Date: SS#: Spouse: Name: Birth Date: SS#:

I WISH TO RECEIVE MY RETIREMENT PENSION IN THE FORM OF THE JOINT AND SURVIVING

    SPOUSE OPTION (“JSO PENSION”), and

CHECK ONE BOX:

     I elect to have my spouse receive 50% of my pension benefits in the event of my death,

     OR

     I elect to have my spouse receive 75% of my pension benefits in the event of my death

I HAVE READ THE JSO PENSION EXPLANATION ON PAGE 8A, AND I UNDERSTAND THE FINANCIAL

    EFFECTS OF THIS SIGNED DOCUMENT ON MY PENSION BENEFIT, INCLUDING (BUT NOT LIMITED

    TO) THE FOLLOWING:

(1) The pension benefit that I would otherwise be eligible to receive will be adjusted to a lesser amount, on

    the basis of actuarial equivalence (as explained on Page 8a and in accordance with the

    accompanying JSO Pension adjustment charts), in order to provide a lifetime benefit to my spouse

    after my death.

(2) For purposes of this election, my “spouse” is the person to whom I am married on my “Effective Date”

    (the first day of the month following my retirement date), and in the event that I designated a

    retroactive retirement date, the person to whom I am still married on my “Initial Payment Date” (the

    date on which the Pension Fund first begins paying my retirement pension). Only the person who is

    my spouse on both my Effective Date and my Initial Payment Date is eligible to receive the survivor

    share of my JSO Pension.

(3) This election is revocable by me up until 90 days after my Initial Payment Date (the date on which the

    Pension Fund first begins paying my retirement pension) but cannot be later revoked or changed

    under any circumstances (except as indicated on page 8a). To be valid, revocation must be

    accomplished by completing and filing with the Fund the WAIVER OF JOINT AND SURVIVING

    SPOUSE OPTION form that has been furnished to me in this packet.

    Participant Signature: Date: Spouse Signature: Date:

    SUBMIT COPIES OF YOUR MARRIAGE CERTIFICATE AND SPOUSE’S BIRTH CERTIFICATE

    WITH THIS ELECTION.

     8

    EXPLANATION OF JOINT AND SURVIVING SPOUSE OPTION

Central States, Southeast and Southwest Areas Pension Fund ("Central States") provides you, as a Participant eligible to receive a lifetime monthly retirement pension, with an optional form of payment, called the Joint and Surviving Spouse Option ("JSO Pension"). If you elect the JSO Pension, your benefit amount will be less than the full retirement pension you have earned. This is because under the JSO Pension form of payment, benefits are paid for the longer of two lives (your and your spouse’s), and therefore your full benefit (which would otherwise be paid out for your lifetime only) must be actuarially reduced. This reduced JSO Pension amount (described below) is paid for your lifetime and upon your death, if that same spouse survives you, he or she will receive a monthly survivor pension (equal to 50% or 75% of your reduced JSO Pension amount) for the rest of his or her life - even if he or she later remarries. The difference between your full retirement pension benefit (which is the amount payable to you if you waive the JSO Pension form of payment and your spouse consents to that waiver) and your JSO Pension amount is determined by (1) your choice of either the 50% or 75% surviving spouse benefit, and (2) your age and your spouse’s age on your retirement date. The accompanying charts outline the various adjustment factors. Federal law requires that if you are married when your retirement pension begins to be paid (your “Initial Payment Date”), to the same person you were married to on the first day for which your retirement pension is payable (your “Effective Date”), your monthly pension must be distributed in the JSO Pension form of payment unless both you and your spouse sign and file with Central States a valid and timely waiver of that option, witnessed and confirmed by a notary public. Description of the JSO Pension

Reduced JSO Pension Amount. Central States will inform you, upon request, of the amount of your full retirement pension

    payable at your selected Retirement Date. This full pension is the unreduced lifetime amount payable to you if you waive the

    JSO Pension and your spouse consents to that waiver.

In addition, Central States will, upon request, provide written confirmation of your reduced 50% or 75% JSO Pension amount.

Effect on Your Spouse of a Waiver of the JSO Pension. If you and your spouse file with Central States a valid, timely and

    jointly signed JSO Pension waiver and, while receiving your full retirement pension, you die and are survived by your spouse,

    your spouse will not receive any further benefits from Central States unless (1) you earned at least 20 years of Service Credit

    (of which at least 10 years is based on Contributions), and you attained age 50 before leaving active participation in Central

    States Pension Fund, or (2) you qualified for a 25-And-Out or 30-And-Out Pension. If you meet the above criteria, your spouse

    will receive (a) the remainder (if any) of the first 60 months of payments of your full retirement pension if you retired at Benefit Class 4 or higher, or (b) a single $1,000 payment if you retired at Benefit Class 3A or lower.

Identification of Your Spouse. For all JSO Pension purposes, your "spouse" is the person to whom you are married both on

    the date on which your retirement pension actually begins to be paid to you ("Initial Payment Date") and on the first day for

    which your retirement pension is payable (“Effective Date”). Thus, if you elect a retroactive Retirement Date and as a result you receive a single retroactive payment of all monthly benefits due from your Effective Date to your Initial Payment Date, only

    the person who is your spouse, both on your Initial Payment Date and on your retroactive Effective Date, is (1) eligible to receive

    the survivor share of your JSO Pension (if the JSO Pension is elected), or (2) authorized to consent to your waiver of your JSO Pension (if the JSO Pension is waived), unless a qualified domestic relations order requires otherwise.

Election Period: Waiver of JSO Pension. To be valid and effective, your and your spouse's jointly signed waiver of the

    JSO Pension, duly notarized, must be filed with Central States within an election period that begins 180 days before your Effective Date and ends 90 days after your Initial Payment Date. Mail your jointly signed (and notarized) waiver of

    the JSO Pension to: Central States, Southeast and Southwest Areas Pension Fund, P.O. Box 5109, Des Plaines, IL

    60017-5109. You may also later send to Central States (P.O. Box 5109, Des Plaines, IL 60017-5109), within the same election period, your signed revocation of a previously submitted JSO Pension waiver. No changes to your pension payment form and amount can be made after that election period expires (except as noted in the next paragraph).

    Increase of JSO Pension Amount After Subsequent Death or Divorce of Your Spouse. If you are receiving a JSO Pension and your spouse (for JSO Pension purposes) dies first, your reduced JSO Pension will be increased to your full retirement

    pension the month after your spouse's death. Or, if you are receiving a JSO Pension and your spouse (for JSO Pension

    purposes) executes a specific written waiver of all rights to and interest in your JSO Pension, and if that waiver is incorporated in a court-approved property settlement agreement that is part of a judgment or order entered by a court of competent jurisdiction in a divorce, marriage dissolution or marital separation proceeding, your reduced JSO Pension will be increased to your full

    retirement pension the month after that judgment or order is entered.

     8a

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