ࡱ> #` }bjbj\.\. v>D>D@ t777b8<8O:<:<<<=d??X!O#O#O#O#O#O#O$PhRGOEMA==MAMAGO<<OQDQDQDMAd<<!OQDMA!OQDQDQD<: O7A|QDD O0OQDS-BSQDSQD4@>[@,QD@$@@@@GOGOCX@@@OMAMAMAMA277 STATE OF DELAWARE STATE BOARD OF PENSION TRUSTEES AND OFFICE OF PENSIONS SLC: D570A Application For Pension I hereby apply for a  FORMDROPDOWN  pension under the  FORMDROPDOWN  Pension Plan effective  FORMTEXT      . Name:  FORMTEXT       S.S. No.:  FORMTEXT       Street Address:  FORMTEXT       Date of Birth:  FORMTEXT       City, State, ZIP+4:  FORMTEXT        FORMTEXT     FORMTEXT       Home Telephone:  FORMTEXT       Agency:  FORMTEXT       Agency DDS:  FORMTEXT       Position:  FORMTEXT       If MARRIED, Spouse Name:  FORMTEXT       Spouse S.S. No.:  FORMTEXT       Date of Marriage:  FORMTEXT       Spouse Date of Birth:  FORMTEXT       If SURVIVOR PENSION, Former Employee s Name:  FORMTEXT       S.S. No.:  FORMTEXT       Date of Death:  FORMTEXT       Date of Birth:  FORMTEXT       CERTIFICATION BY AGENCY I hereby certify that all information given for  Name  , applicant for pension, is accurate and true to the best of my knowledge and belief. (Authorized Agency Signature) (Title) (Date) Prepared by: Phone No.: Preparers SLC: Schedule of Creditable Service for Name:  Name   SSN:  SSN   NOTE: Pre 1999 - Breaks in service listed on pay-cycle basis. Total service reflected by paycycle. Post 1998 Breaks in service listed on day-by-day basis. Total service reflected by day. FROMTHROUGHPERIOD COVEREDEMPLOYED BY STATE MonthDayYearMonthDayYearYearsMonthsDaysAGENCY OR SCHOOL  TOTAL CREDITABLE SERVICE FORMTEXT $  * , . T V r t v       2 4 6 @ B ` f h ܵܨҘ܄ҘܑwҘґj{hVCJUjhVCJU hV>*CJjhVCJUmHnHujThVCJUj|hVCJUjhVhVCJUjhVCJU hVCJ hV5CJhV hV5 hVCJ hV5CJ.$dl D 2 p r t  !     dh  dh  $  dh&d P a$$  a$$a$V|}h | ~    " $ & ( < > @ D F H J ^ ` b l n p j hVCJUj hVCJUj hVCJUjhVCJUjhVCJU hV>*CJjhVCJUmHnHujhVCJUjhVCJU hVCJ3  " $ . 0 2 B H J ^ ` b l n p t z    : @ B V X Z ҾұҭҦҙҌj hVCJUj hVCJUj hVCJU hV6CJhVj hVCJUjW hVCJU hV>*CJ hVCJjhVCJUmHnHujhVCJUj hVCJU2t  F789?mno ht"`' bBht"`'d  `'  dh $  dha$  &d P     dhZ d f h  468BDFTZ\prt~ و hV>*jhVCJUjBhVCJUjhVCJUj)hVCJU hV6CJhVjhVCJU hV>*CJ hVCJjhVCJUjhVCJUmHnHu4F9:;<=?m|} vvvv vv v"v&v(v*v,v罹j0hVUjhVUmHnHuUjH0hVUjhVUhV hV5 hV5CJ hV6 hV>*CJ hV5CJh5$sCJmHnHujhVCJU hVCJhV5>*CJ6oO $$Ifa$    `'&d P $  dh&d P a$ hP`' hP`' ^YPPPPPPP $$Ifa$$a$kd$$Ifl4\ *   B     t'(4 lalp(   !"#$%& $If`$a$Ff $$Ifa$&'(" $$Ifa$kdX$$If4 J ( r^*J JJJJJJX  t'((((af4()*+,-./01 $If` $$Ifa$ 123" $$Ifa$kd$$If4 J ( r^*J JJJJJJX  t'((((af43456789:;< $If` $$Ifa$ <=>" $$Ifa$kd$$If4 J ( r^*J JJJJJJX  t'((((af4>?@ABCDEFG $If` $$Ifa$ GHI" $$Ifa$kdH$$If4 J ( r^*J JJJJJJX  t'((((af4IJKLMNOPQR $If` $$Ifa$ RST" $$Ifa$kd$$If4 J ( r^*J JJJJJJX  t'((((af4TUVWXYZ[\] $If` $$Ifa$ ]^_" $$Ifa$kd$$If4 J ( r^*J JJJJJJX  t'((((af4_`abcdefgh $If` $$Ifa$ hij" $$Ifa$kd8$$If4 J ( r^*J JJJJJJX  t'((((af4jklmnopqrs $If` $$Ifa$ stu" $$Ifa$kd $$If4 J ( r^*J JJJJJJX  t'((((af4uvwxyz{|}~ $If` $$Ifa$ ~" $$Ifa$kd!$$If4 J ( r^*J JJJJJJX  t'((((af4 $If` $$Ifa$ " $$Ifa$kd(#$$If4 J ( r^*J JJJJJJX  t'((((af4 $If` $$Ifa$ " $$Ifa$kdx$$$If4 J ( r^*J JJJJJJX  t'((((af4 $If` $$Ifa$ " $$Ifa$kd%$$If4 J ( r^*J JJJJJJX  t'((((af4 $If` $$Ifa$ " $$Ifa$kd'$$If4 J ( r^*J JJJJJJX  t'((((af4 $If` $$Ifa$ " $$Ifa$kdh($$If4 J ( r^*J JJJJJJX  t'((((af4 $If` $$Ifa$ " $$Ifa$kd)$$If4 J ( r^*J JJJJJJX  t'((((af4 $If` $$Ifa$ " $$Ifa$kd+$$If4 J ( r^*J JJJJJJX  t'((((af4 $If` $$Ifa$ " $$Ifa$kdX,$$If4 J ( r^*J JJJJJJX  t'((((af4 $If` $$Ifa$ " $$Ifa$kd-$$If4 J ( r^*J JJJJJJX  t'((((af4 $If` $$Ifa$ " `kd.$$If4 J ( r^*J JJJJJJX  t'((((af4v*vLvtv $If` $ $Ifa$ $If $If`   FORMTEXT    FORMTEXT    FORMTEXT       OTHER FULL TIME SERVICE - Eligible for credit under Buy-In provisions - List separately and attach verification if other than State of Delaware employment.FROMTHROUGHPERIOD COVEREDDESCRIPTION OF BUY-INMonthDayYearMonthDayYearYearsMonthsDaysSERVICE  TOTAL ELIGIBLE BUY-IN SERVICEGRAND TOTAL SERVICE FOR COMPUTING PENSION CERTIFICATION BY APPLICANT I have reviewed the application for pension and hereby agree/disagree (must circle one) on the accuracy of the creditable service schedule information as submitted by the Agency. (Signature of Applicant) (Date) Sworn to and subscribed before me this _____ day of ______________, 20____. 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PensionTypePlanName EffectiveDateNameSSNAddress BirthDateCityStateZIPPhoneAgencyPosition SpouseName SpouseSSN SpouseDOB FormerName FormerSSNDeath FormerDOBSERVICE4W%Uz.Ru<  !Fi7g"@dN r dOr 4r r O   9*urn:schemas-microsoft-com:office:smarttagsState9*urn:schemas-microsoft-com:office:smarttagsplace (EM@ @ B B C C E F H I K L beZ`@ @ B B C C E F H I K L 333!3FVi$7Tgy"-@Qdt)*:;N? @ @ B B C C E F H I K L ] g @ @ B B C C E F H I K L XE45$s VEZO  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~*;OPQ  !'+06:?ELQYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~> ? @ B E H K )@XG@ PP PP @PvUnknownGz Times New Roman5Symbol3& z Arial"h9f9f$4d; ; 2HP ?5$sApplication for PensionPension OfficePension OfficepensionOh+'0 , L X d p|Application for PensionPension OfficePensionApplication.dotPension Office2Microsoft Office Word@F#@@^K@^K՜.+,0 hp  State of Delaware;  Application for Pension Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTVWXYZ[\]^_`abcdefghijklmnopqrstvwxyz{|}~Root Entry FOData U?1TableuSWordDocumentvSummaryInformation(DocumentSummaryInformation8CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q