ࡱ> LNKq  bjbjt+t+ '@AA]8:D~\BB`$I=|6]^^^6````^^``&D STATE OF DELAWARE VOLUNTEER FIREMEN S PENSION PLAN Application For Pension I hereby apply for a Delaware Volunteer Firemen  FORMDROPDOWN  pension under the provisions of Title 16, Chapter 66A effective  FORMTEXT      . Name:  FORMTEXT       S.S. No.:  FORMTEXT       Street Address:  FORMTEXT       City, State, ZIP:  FORMTEXT        FORMTEXT     FORMTEXT       Date of Birth:  FORMTEXT       Company:  FORMTEXT       Telephone:  FORMTEXT       CERTIFICATION BY APPLICANT I have reviewed and hereby certify that all information is accurate and true to the best of my knowledge and belief. Sworn to and subscribed before me this _____ day of ______________, 20____. (Notary Public) (Signature of Applicant) CREDITABLE SERVICE OF MEMBER FROMTHROUGHPERIOD COVEREDNAME OF VOLUNTEERMonthDayYearMonthDayYearYearsMonthsDaysORGANIZATIONTOTAL ACTIVE SERVICE PRIOR FORMTEXT      TO 1/1/86  FORMTEXT       YEARS FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      TOTAL CREDITABLE SERVICE FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       CERTIFICATION BY ORGANIZATION I hereby certify that all information given for  Name  , the applicant for pension, is accurate and true to the best of my knowledge and belief. (Authorized Signature) (Title) (Date) FORM-AP-F (Rev. 1/00) $fhj*,.8:X^`tvxjC5CJUj5CJUj75CJUj5CJU>*CJj5CJUmHj5CJUj5CJU5CJj5CJUCJ5CJ5CJ5CJ6$&hj<b      $dh     dh   dh  dh     $dh&d   $  $$&hj<b  ( 7 I J P T Y _ c h n u z    ` b d f h j l n p r t v x  @ h  2 Z  c  6:<PRT^`bprtvx  ɜɘɜ56CJCJ 5>*CJj5CJUj`5CJUj5CJUCJ>*CJj<5CJUj5CJU5CJj5CJUj5CJUmH; ( 7 I J P T Y _ c @$$l4 t'\ *       $$   dh   b (# x(#  c h n u z t,$$4 t' J ( r^*   $$ xz$$4 t' J ( r^*  $$$$  , . B D F P R ` x z       . 0 2 < > @ B V X Z d f h jy Uj Ujs UjUjfUjUjCJUmHjCJU jCJU jUmHjU jUCJ>    ` b d ,z$$4 t' J ( r^*  $$d f h j l n p r t v x  z$z$$4 t' J ( r^*  $$$ @ h  2 Z " z$z$$4 t' J ( r^*  $$$h j ~   " $ . 0 2 4 H J L V X Z \ p r t ~ j!UjUjUj Uj Uj Uj Uj U jUmHj U jUA " J r <d,.V~Fn8Zyz~  3     " $ 8 : < F H J L ` b d n p r t *,.8:<>RTjKUjUj@UjUj3UjUj-UjUj&U jUmH jUjU@" J r <d,z$z$$4 t' J ( r^*  $$$TV`bdfz|~(*.0DFHRTVXlnpz|~jUjjUjUj]UjUjWUjUjPUjU jUmH jUC,.V~Fn$zq $ $$$z$$4 t' J ( r^*     468BDFH\^`jlnp  ,.0468:NPRVXZ\pjzUjUjU5jUjUjUjzUjU jUmHjuU jUB8Zyz~|sii  (# x(#   $dh   O$$ t'ֈ^*         $ $$ $  prt~yz{}~6CJ>*CJ>*CJ 5CJmH jCJUCJ 5>*CJ5 jUmH jUjU#  (# x(#0* % 0 00/ =!"#$%Df PensionType2Choose the type of Pension from the Drop-Down listServiceVestedD EffectiveDate MMMM d, yyyy=Type in the Effective Date of Pension in June 30, 1997 formatDName Title CaseType the Applicant's NameD SSN+Type the Applicant's Social Security NumberDAddress#Type the Applicant's Street AddresswDCityType the Applicant's CityDState UppercaseType the Applicant's StatezD ZIPType the Applicant's ZIP CodeD BirthDate MMMM d, yyyy;Enter the Applicant's Date of Birth in June 30, 1947 formatDCompanyDType the Name of the Fire Company or Ladies Auxillary retiring from.DPhone!Type the Applicant's Phone NumberDText1:Type One-Third of the Total Active Service Prior to 1/1/86DSERVICE`Type in the total years and months of service prior to January 1, 1986 (e.g. 28 years 3 months)DText2(Type Month of Beginning Credible ServiceDText3'Type Day of Beginning Credible Service DText4(Type Year of Beginning Credible Service DText5%Type Month of Ending Credible ServiceDText6#Type Day of Ending Credible ServiceDText7$Type Year of Ending Credible ServiceDText8$Type Total Years of Credible ServiceDText9%Type Total Months of Credible ServiceDText10#Type Total Days of Credible ServiceDText11#Type Name of Volunteer OrganizationDText2(Type Month of Beginning Credible ServiceDText3'Type Day of Beginning Credible Service DText4(Type Year of Beginning Credible Service DText5%Type Month of Ending Credible ServiceDText6#Type Day of Ending Credible ServiceDText7$Type Year of Ending Credible ServiceDText8$Type Total Years of Credible ServiceDText9%Type Total Months of Credible ServiceDText10#Type Total Days of Credible ServiceDText11#Type Name of Volunteer OrganizationDText2(Type Month of Beginning Credible ServiceDText3'Type Day of Beginning Credible Service DText4(Type Year of Beginning Credible Service DText5%Type Month of Ending Credible ServiceDText6#Type Day of Ending Credible ServiceDText7$Type Year of Ending Credible ServiceDText8$Type Total Years of Credible ServiceDText9%Type Total Months of Credible ServiceDText10#Type Total Days of Credible ServiceDText11#Type Name of Volunteer OrganizationDText2(Type Month of Beginning Credible ServiceDText3'Type Day of Beginning Credible Service DText4(Type Year of Beginning Credible Service DText5%Type Month of Ending Credible ServiceDText6#Type Day of Ending Credible ServiceDText7$Type Year of Ending Credible ServiceDText8$Type Total Years of Credible ServiceDText9%Type Total Months of Credible ServiceDText10#Type Total Days of Credible ServiceDText11#Type Name of Volunteer OrganizationyD Enter the total number of yearszD  Enter the total number of monthsxD Enter the total number of daysDSERVICEFType in the total years and months of service (e.g. 28 years 3 months) [$@$NormalmH <A@<Default Paragraph Font,@,Header  !, ,Footer  !@ h Tp c d  " ,   ~ /;AUagiuxz'-/;ACOUWcikw}   ,24@FHTZ\hnp| #%179EKMY_bntv"(EQTVbegsvxS FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF PensionType EffectiveDateNameSSNAddressCityStateZIP BirthDateCompanyPhoneText1SERVICEText2Text5Text6Text8Text10Text11Text3Text4Text7Text9 0Vj{0l Bhy.BVj~~ /BUhiyz./BCVWjk~   34GH[\op$%89LM`buv)EUVfgwx5ADL~ ,/BUhiyz./BCVWjk~   34GH[\op$%89LM`buv)EUVfgwxC Joanna AdamsG\\OPEN-2K1\FS_DATA\Shared\FIREMEN\Templates\PensionApplication_Fire.dot@~@~~X```@` ```$@G:Times New Roman5Symbol3& :Arial"h݂ނ";&C A#0diSTATE OF DELAWARE Joanna Adams Joanna Adams Oh+'0 , H T ` lxSTATE OF DELAWAREdTAT Joanna AdamsWARoanPensionApplication_Fire.dot Joanna Adamsati1anMicrosoft Word 8.0F@F#@1=@F@S; ՜.+,D՜.+,L hp  Office of Pensions1 STATE OF DELAWARE Title 6> _PID_GUIDAN{F6361587-A36D-11D5-85CE-00C04F7F11EF}  "#$%&'()*+,-./023456789:<=>?@ABDEFGHIJMRoot Entry FR& &OData !1Table1WordDocument'@SummaryInformation(;DocumentSummaryInformation8CCompObjjObjectPool & &  FMicrosoft Word Document MSWordDocWord.Document.89q