Download January 24, 2003 - Water and Power Employees` Retirement Plan

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Instructions – Retirement Application Form
The “Application for Retirement” (Page 2) and “Personal Data Sheet for Retirees” (Pages 3-4)
are used to apply for retirement from active service. If you need information on your eligibility to
retire, please contact the Retirement Plan Office at (213) 367-1715.
Steps for completing the “Application for Retirement” form
(see page 2)
The “Application for Retirement” should be completed and printed on Department
letterhead. Your retirement date must be on the 1st of the month. Your application
must be received by the Retirement Plan Office at least 30 calendar days prior to
your retirement date. Thirty days prior is mandatory per the City Charter. We
cannot accept a late application. Therefore, you should notify your division of your
intent to retire at least 60 days prior to your desired retirement date.
If you are younger than age 60 on your retirement date, the application must be
approved by your Division Director and routed to the Retirement Plan Office
through your Division.
If you are age 60 or older on your retirement date, you may deliver the application
directly to the Retirement Plan Office. Your Division Director’s approval is not required.
Notes:
It is your responsibility to review the accuracy of the information on the application
before you sign it. If any changes are needed, please initial the corrections. Do NOT
use correction tape (whiteout).
The Retirement Plan Office will only accept an original signed application. We will not
accept a copied, emailed, or faxed application.
Steps for completing the “Personal Data Sheet for Retirees” form
(see pages 3-4)
The “Personal Data Sheet for Retirees” is a separate form used to gather personal
and confidential information for your retirement. The information is used by staff to
assist in the calculation of your benefits and to assist you through the retirement
process. The information will not be shared with your Division or anyone outside of
the Retirement Plan Office.
If you have any concerns or questions that are not addressed in the form, please
address them directly with your assigned retirement counselor.
The more
information that we have about your particular situation; the more we can customize
the retirement counseling to meet your needs.
Please deliver the completed form directly to:
Retirement Plan Office
John Ferraro Building, Room 357
7:00 a.m. thru 4:00 p.m.
If you have any questions, please call (213) 367-1715.
(Rev. 10/20/2016)
The Honorable Board of
Water and Power Commissioners
ATTN: Retirement Plan Office
Room 357, John Ferraro Building
Date: August 13, 2017
Honorable Members:
APPLICATION FOR RETIREMENT
I am applying for retirement to be effective on
,
, when I will be
years of age. This application is made pursuant to the provisions of the Retirement Plan and
Section 1184 of the Los Angeles City Charter.
I currently work in the
Division. I understand that this application must be filed with the Board
of Administration of the Water and Power Employees’ Retirement Plan at least thirty (30) calendar
days prior to the retirement date I have specified above. I will only be retired if I meet all eligibility
requirements.
I also understand that should I choose to withdraw my retirement request, I must do so by
written, signed, notification, which must be received by the Retirement Plan Office no later
than seven calendar days prior to my requested retirement date.
Sincerely,
Employee Signature
Date
Name:
Employee No.:
Payroll No.- Section No.:
Department Phone(s):
-
(
)
-
Recommended:
Approved:
David H. Wright
General Manager
(Name of Division Head)
(Title of Division Head)
PERSONAL DATA SHEET FOR RETIREES
PLEASE TURN THIS FORM INTO THE RETIREMENT PLAN OFFICE (JFB - ROOM 357)
DO NOT SUBMIT THIS FORM TO YOUR DIVISION
*** THIS FORM IS NOT AN APPLICATION FOR RETIREMENT***
TARGETED EFFECTIVE RETIREMENT DATE:
Member – Job Information
Name:
Employee No.:
Civil Service Class:
Division:
-
Payroll No.:
Department Phone:
(
)
-
Member – Personal Information
Social Security Number:
XXX - XX -
Birth Date:
Home Address:
(cont)
City, State Zip Code:
,
Home Phone:
(
)
-
Mobile Phone:
(
)
-
E-Mail Address:
Member – Service Information
Prior City service (check one)?
No
Yes
If “Yes”, do you have funds on deposit with LACERS?
No
Yes
Have you applied to retire with LACERS?
No
Yes
No
Yes
No
Yes
Prior Department/Government Service?
Do you have any questions about purchasing time?
Spouse or Domestic Partner – Information
Name
Date of Birth
Social Security #
-
-
Date of Marriage/Partnership
City/State of Marriage/Partnership
Is Spouse/Domestic Partner a Department Employee
No
Yes
No
Yes
If yes, employee #
Member’s Divorce History
Have you ever been divorced?
If yes, name of prior spouse
Member’s Children – Information
Name
Date of Birth
Social Security #
Phone #
(
-
)
-
Address
City, State Zip
,
Relationship
Name
Date of Birth
Social Security #
Phone #
(
-
)
-
Address
City, State Zip
,
Relationship
**Use an additional page for more than two children.**
PLEASE TURN THIS FORM INTO THE RETIREMENT PLAN OFFICE (JFB - ROOM 357)
PLEASE DO NOT SUBMIT THIS FORM TO YOUR DIVISION
If you have any questions, please call (213) 367-1715. Thank you.
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