ࡱ> %` }bjbj"x"x v@@@ t777b8<84Q:<:<<<=d??X=OHPPPPPP$QhRTPEMA==MAMAP<<P]D]D]DMAd<<=O]DMA=O]D]D]D<: S=7A|]DD Q04Q]DT-BT]DT]DD@>[@,]D@$@@@@PPDX@@@4QMAMAMAMA277 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 ܸܕ҅~q҅~jhVCJU hV>*CJjhVCJUmHnHujhVCJUj|h,`h,`CJU h,`CJjh,`CJUjhVhVCJUjhVCJU hVCJ hV5CJhV hV5 hVCJ hV5CJ'$dl D 2 p r t  !     dh  dh  $  dh&d P a$$  a$$a$V|}2 4 6 @ B ` f h | ~    " $ & ( < > @ D F H J ^ ` b l n p ˾˱ˤ˗ˊj hVCJUjhVCJUjhVCJUj hVCJUjhVCJU hVCJ hV>*CJjhVCJUmHnHujhVCJUjhVCJU1  " $ . 0 2 B H J ^ ` b l n p t z  ҾұҤҠҙҌj hVCJUj hVCJU hV6CJhVj hVCJUj hVCJUj< hVCJU hV>*CJ hVCJjhVCJUmHnHujhVCJUj hVCJU2t  F789?mno ht"`' bBht"`'d  `'  dh $  dha$  &d P     dh   : @ B V X Z d f h  468BDFTZ\prt~ؾغسئؙ،jhVCJUj/hVCJUjhVCJU hV6CJhVjhVCJUj& hVCJU hVCJ hV>*CJjhVCJUmHnHujhVCJU7 F9:;<=?m|} vý諽ѽѽѦѽѽѽ蚖Uj/hVUjhVUhV hV5 hV5CJ hV6 hV5CJh,`CJmHnHu hVCJhV5>*CJ hV>* hV>*CJjhVCJUmHnHujhVCJUjphVCJU1oO $$Ifa$    `'&d P $  dh&d P a$ hP`' hP`' ^YPPPPPPP $$Ifa$$a$kd$$Ifl4\ *   B     t'(4 lalp(   !"#$%& $If`$a$Ff? $$Ifa$&'(" $$Ifa$kd$$If4 J ( r^*J JJJJJJX  t'((((af4()*+,-./01 $If` $$Ifa$ 123" $$Ifa$kd*$$If4 J ( r^*J JJJJJJX  t'((((af43456789:;< $If` $$Ifa$ <=>" $$Ifa$kdz$$If4 J ( r^*J JJJJJJX  t'((((af4>?@ABCDEFG $If` $$Ifa$ GHI" $$Ifa$kd$$If4 J ( r^*J JJJJJJX  t'((((af4IJKLMNOPQR $If` $$Ifa$ RST" $$Ifa$kd$$If4 J ( r^*J JJJJJJX  t'((((af4TUVWXYZ[\] $If` $$Ifa$ ]^_" $$Ifa$kdj$$If4 J ( r^*J JJJJJJX  t'((((af4_`abcdefgh $If` $$Ifa$ hij" $$Ifa$kd$$If4 J ( r^*J JJJJJJX  t'((((af4jklmnopqrs $If` $$Ifa$ stu" $$Ifa$kd $$If4 J ( r^*J JJJJJJX  t'((((af4uvwxyz{|}~ $If` $$Ifa$ ~" $$Ifa$kdZ!$$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$kdJ%$$If4 J ( r^*J JJJJJJX  t'((((af4 $If` $$Ifa$ " $$Ifa$kd&$$If4 J ( r^*J JJJJJJX  t'((((af4 $If` $$Ifa$ " $$Ifa$kd'$$If4 J ( r^*J JJJJJJX  t'((((af4 $If` $$Ifa$ " $$Ifa$kd:)$$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$kd*-$$If4 J ( r^*J JJJJJJX  t'((((af4 $If` $$Ifa$ " `kdz.$$If4 J ( r^*J JJJJJJX  t'((((af4v*vLvtv $If` $ $Ifa$ $If $If`   FORMTEXT    FORMTEXT    FORMTEXT       OTHER FULL TIME SERVICE - Eligible for credit under Buy-In provisions - List separately and attach verification if other than State of Delaware employment.FROMTHROUGHPERIOD COVEREDDESCRIPTION OF BUY-INMonthDayYearMonthDayYearYearsMonthsDaysSERVICE  TOTAL ELIGIBLE BUY-IN SERVICEGRAND TOTAL SERVICE FOR COMPUTING PENSION CERTIFICATION BY APPLICANT I have reviewed the application for pension and hereby agree/disagree (must circle one) on the accuracy of the creditable service schedule information as submitted by the Agency. (Signature of Applicant) (Date) Sworn to and subscribed before me this _____ day of ______________, 20____. (Notary Public     FORM  CS-1 Page  PAGE 2 of _____ FORM AP Page  PAGE 1 of _____ (Rev. 04/2004) FORM-CC-1 FORM-CS-1 Page  PAGE 3 of _____ vvvv vv v"v&v(v*v,v@vBvDvHvJvLvNvbvdvfvpvrvtvvvvwwyLyPyyyyLzhzF{H{J{N{{.|0|4|P|V|X|\|^|b|d|h|j|n||ᷱᔐhjhU hV6CJ hV>*CJ hV5CJ hVCJhV5>*CJj51hVUj0hVUjC0hVUhV hV5jhVUjhVUmHnHu7tvvvxvwwoeW&1kd2$$If5**    t'a $If` `kd1$$Ifֈf*   C W      t'awwwwxx$x,x6xBxJx[kdh3$$If\ *  B    t'ap $ $Ifa$ $$Ifa$ JxTx`xnxxxx $ $Ifa$ $$Ifa$xxx% $a$kdy4$$If J ( r^*J JJJJJJX   t'((((axxxxxxxxxxx $If` $$Ifa$ xxxx% $$Ifa$kd5$$If J ( r^*J JJJJJJX   t'((((axxxxxxxxx $If` $$Ifa$xxxx% $$Ifa$kd)7$$If J ( r^*J JJJJJJX   t'((((axxxxxxxxx $If` $$Ifa$xxxx% $$Ifa$kd8$$If J ( r^*J JJJJJJX   t'((((axxxxxxxxx $If` $$Ifa$xxxx% $$Ifa$kd9$$If J ( r^*J JJJJJJX   t'((((axxxxxxxxx $If` $$Ifa$xxxx% $$Ifa$kd1;$$If J ( r^*J JJJJJJX   t'((((axyyyyy y yy $If` $$Ifa$yyy% `kd<$$If J ( r^*J JJJJJJX   t'((((ayNyPyyyyyD{F{qaR bBdh$If  dh$C$If$  dh$Ifa$  dh2kdO>$$If4**    t'af42kd=$$If4**   t'af4 $If`F{N{{{*|,|.|2|R|T|V|Z|\|yomm  dh5kd>$$Ifl4*+4 laf4 b (#$If x(#$If  $If $If] $If P$$If \|`|b|f|h|l|n||||| }"}6}8}}}}}  dh^  !+^|||||||||||||}X}Z}f}h}j}l}~}}}}hhV0JmHnHuhVh0JmHnHu hV0JjhV0JU6 00&P/R / =!"#$%h 2 0 0/R / =!"#$% 5 0 00/R / =!"#$% 2 0 0/R / =!"#$% 2 0 0/R / =!"#$% 5 0 00/R / =!"#$% 2 0 0/R / =!"#$% |Df PensionType2Choose the type of Pension from the Drop-Down listServiceReduced/Service Reduced/Age DisabilitySurvivorVested Vested LTDZDfPlanName2Choose the type of Pension from the Drop-Down list State Employees' (A001)State Police - 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PensionTypePlanName EffectiveDateNameSSNAddress BirthDateCityStateZIPPhoneAgencyPosition SpouseName SpouseSSN SpouseDOB FormerName FormerSSNDeath FormerDOBSERVICE4W%Uz.Ru<  !Fi7g"@dN (<)<=,*< i*+<   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$7Tgy"-@Qdt)*:;N? @ @ B B C C E F H I K L ] g @ @ B B C C E F H I K L   XE_+45$s VEZ,`O  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~*;OPQ  !'+06:?ELQYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~> ? @ B E H K )   ( Ado&be PDFCreateAdobePDF7.0Custom Popup 1014178218 (Acrobat &CommentsImportComments6Custom Popup 1014178234% NO O@y @   @vUnknownGz Times New Roman5Symbol3& z Arial"h tF tFy$4d; ; 2HP ?,`2Application for Pension larry.lim larry.limpensionOh+'0 $ D P \ ht|Application for Pension larry.limPensionApplication.dot larry.lim2Microsoft Office Word@@@D=@D=՜.+,0 hp  State of Delaware; ' Application for Pension Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTVWXYZ[\]^_`abcdefghijklmnopqrstvwxyz{|}~Root Entry FS=Data U?1TableuTWordDocumentvSummaryInformation(DocumentSummaryInformation8CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q