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HomeMy WebLinkAboutReel_0024C (35)n u ?` m V !(?? w Y` A U o: e a o M x • F W O a o, a ?N z z ?? c a H H W H x ? w QF' F Z9 $a a Ga ? w C w 4 O W cW F x yw yOy W J H W i a a? i w? c"?aE i O Y? a 8E 7 an W v S _ u ?FY F tw Cc a$ h$ hIJ?? TW 3 S? ey E 0. we ` K? s x? sH ?a K_ E? w ?a 3E rn O w?°" YlILT r ? I 9 ? J ?I .f1 T I I / ? i r? ? N i t I ? I rl a 0 1 BL?r_y v Y D b? 1 J WASHIN STATE uEPAflTMENT OF RETIREMENT SYS REQUEST FOR REFUND OF CONTRIBUTIONS FOR DRS USE ONLY INSTRUCTIONS: COMPLETE ALL SECTIONS. INCOMPLETE APPLICATIONS WILL BE Dovr. UNIT DEPT. RETURNED. CAREFULLY READ THE INFORMATION PROVIDED AND BE CERTAIN YOU UNDERSTAND THE EFFECTS OF WITHDRAWING YOUR FUNDS. SECTION ONE - IDENTIFICATION, COMPLETE IN FULL. SEX LAST NAME FIRST NAME MIDDLE NAME MAIDEN NAME ® M ? F Baumunl< AL Lan James OTHER NAME(S) YOU HAVE USED WHEN EMPLOYED SOCIAL SECURITY NUMBER TEACHERS' MEMBER NUMBER 538-42-9560 I was a contributing member of (Check the system and plan): Public Employees' Retirement System (PERS) ....................... N Plan 1 = 0 .. ? Plan II = 7 Law Enforcement Officers' and Fire Fighters' Retirement System (LEOFF) ................................... ? Plan I = 1 .. ? Plan II = 8 Teachers' Retirement System (TRS) .............................. ? Plan I ..... ? Plan II State Patrol Retirement System (WSP) .... El 3 ................ (No plan designation required) until I terminated employment with JeffM'son County FLbLLc lklorks an Septmi:To- 28, 1984 (L..t EmP OY.r) IMO.) (D.Y) (Y,.) ® expect to receive September 28, 1984 I my final salary payment on D received IMOnIn) (Y..n Your withdrawal is subject to Federal Income Tax withholding If the interest portion exceeds $200, unless you elect not to have withholding apply. Even if you elect not to have Federal Income Tax withheld, you are liable for payment of Federal Income Tax on the taxable (interest) portion of your withdrawal. You also may be subject to tax penalties under the estimated tax payment rules if your payments of estimated tax and withholding, it any, are not adequate. Unless you elect otherwise, 10% of the Interest portion will be withheld from your refund. You may exercise your right to elect not to have tax withheld though, by signing In the space below. I DO NOT want to have Federal Income Tax withheld from my withdrawal. I Signature I SECTION FOUR - MAILING ADDRESS FOR THE REFUND. PLEASE PRINT P.O. ilox 564 ChiInacun) Wa. 98325 STREET CITY STATE TIP "IMPORTANT" Ruud the information on the reverse side of this form and have your signature notarized in the space provided. (Section 8) 4 4T - *? ( as Kr *nw . ??1 X11 z5?;?, . •??Rrmh4Y:'SMf. -hsvr,. ?r+ti?.R wi3E b?"i.J.wu.?{R? TL .N'Y.S'?r=}?asLT! a1??.?71A ??°,(ia,.?'?. .si?Or"itr.? "?????'. :?..?: 9i? - - IMPORTANT SS P '? Withdrawing your retirement funds is strictly, voluntary. You need not withdraw your funds because you have terminated employmunt. Your money will continue to earn interest until you return to covered employment in the same system. There are time limitations in some systems. Each retirement system has disability coverage. If you are withdrawing due to illness or disability, you should check with a retirement eounealor for your system before terminating your account. Any withdrawal terminates all rights - for future benefits. -- Normal processing lime for payment takes from 60 to 90 days. Forms received unsigned will be returned for d ' notarized signature prior to processing. Members of PERS cannot withdraw their funds if employed in an eligible position or while on authorized leave of absence. Separation from one employer to take a position with another within 30 days renders one ineligible for withdrawal. Return to eligible employment prior to receipt of the warrant also renders one ineligible; and the monies, if received, must be repaid. Upon termination a PERS Plan I member may make a one-time request to withdraw an amount less than the total balance. Additional information can be obtained by contacting this agency. Members of LEOFF cannot withdraw their funds it employed in an eligible position or while on authorized leave of , absence. Members of TRS are not eligible to withdraw their contributions until they have terminated all public school employment and have no commitments, written or oral, for such employment. If a member applies for withdrawal and returns to employment prior to receipt of the warrant, het she is deemed ineligible to withdraw and must return any monies received. In the TRS a withdrawal cancels all rights under the Retirement System, and any future return to membership may or may not allow restoration of previous credit, depending on the laws in effect at the time. - Members of WSP may withdraw their contributions upon separation from employment with the State Patrol. f Members of all systems with more than live (5) years of service credit with a retirement system are vested with a right to benefits at retirement age provided the contributions are not withdrawn. p if you should decide to remain a member of your system after you receive the refund, the check may be returned uncashed within a reasonable time and the amount will be credited to your account together with the service credit it represented. If you have any questions, please feel free to contact this department by phone (206) 753.5287, or by mail in care of Mai: ,r. Stop ES-11, Olympia 98504. " SECTION FIVE - WHERE WE CAN CONTACT YOU IF NECESSARY STREET CITY STATE ZIP 7076 Center Road Chiuuacutn Loa. 98325 TELEPHONE -.AREA CODE - PHONE NIJ.BER Message Phone OnLy (206) 358-3505 SECTION SIX - NOTARIZATION OF YOUR SIGNATURE. READ CAREFULLY. _I I cerlify that I am not on leave of absence, have terminated all employment covered by my retirement system, and have no arrangements for employment in accordance with the applicable laws. I understand that even a partial withdrawal nullifies any claim or right that 1 have to benefits which may have accrued to me as a member of that system. „ / _ /, SURSCRIP. 17) Atop-61dORN TO before me this '1911 day of ? Sopinmhar , 19 84 Residing at Fort Townsend, WashLngton 'RETURN COMPLET&O ORM TO: DEPARTMENT OF RETIREMENT SYSTEMS 1025 E. Union Mail Stop ES 11 Olympia, WA 98504 -??Seulcn' 7664 "POS4R•' Reulln9'Re4ues ?. ROUTING - REQUEST { Y? Please ? READ To E ? HANDL ;? ? APPROVE I'>. r 1? f F?f? and ? i 7 ?' ? ? FORWARD ? RETURN - ? KEEP OR DISCARD Y4 - ? REVIEW WITH ME C Oala ? F m 3 WE, Am -Mll ? r77 4Fn% n y F &?k. Ji, tot. _ - ?i?`ada'!?1`s t?2h- ..?'?iaL'? ?+.8 ?3YFG4 .,,':,....i,d1"'5+nk8 v.... s,,.. e?.: J..,.,^,SC''_ df.?'??dLt?,s.?ea? ar PO a 77. ?? /71.1'J , ?) L?-w y ?u+sc..yb r,, y ws d ?. qlg? ? ?, b t , zC a'J '. .? l TO JEFFERSON COUNTY DEPARTMENT OF PUBLIC WORKS • . . 1 ? COURTHOUSE J F PORT TOWNSEND WASHINGTON 98368 R O PHONE - 385-3505 ' - SUBJECT. a -MESSAGE ------ - ------------ _ f --------- ----- - SIGNED DATE " REPLY T J? " ?. _ •• REMOVE PART ZAND FORWARD PARTS t.AND J. PART S WILL BE RETURNED WITH REPLY. SIGNED,, _ / ^; f?. DATE '-, ,/,? / - • f% a a X11 LIFT THIS SHEET TO REMOVE • FILE FOR FOLLOW-UP,,'' n D f r hS ?,,i+ ..•il'.? ,.lc n. a7:.:. .;r. .. ., ..- ti Hd 4Rb'+.17,'[Y1.P :,.T:: ?l ?h'CA1c'.wuTV li?rl?-1? 4 $ +n.f S k g'' p .,tN(. pry +y'?j 04 FROM JEFFERSON COUNTY DEPARTMENT OF PUBLIC WORKS ,. . ? -- __---- ----- - ___ --- ----- COURTHOUSE T o PORT TOWNSEND WASHINGTON 98368 PHONE - 385.3505 SUBJECT - -MESSAGE _ -? .- /i l i/ 7F ?;//- li// .,'E ;;/? (XCi/. is .: /!-'[?'? % /?'l(? --- i rr //? •J)E,vJ r .-,v , ?i?- J; «? r « ,/ =^,auJ.-ilH.. <, 1 a ..SIGNED DATE,r ty { it REPLY i ./ r r. w REMOVE PART2 AND FORWARD PARTS I AND 8. PART 3 WILL BE RETURNED WITH REPLY. SIGNED DATE " - :-..G 4 ? Ilk, N?i?f h i qpl db{...rS? '!M '!1i l . u Jl.Iln..'1LY ? ? q^ i _ tl IJ 6'? 1 Gf 4 an Ka ESTIMATE OF REPAIR COSTS LABOR HRS pARiS G<? TOTAL j OWuoflbla Paid in fun on compbllon of ppalls. Hna Or uson. a ?an na, A ?AnT• 1 ?AIwT wnnlAls 1 b TOWING S SAlaa TAA / S { TOTAL I 'I "' 1 -'n? WORKER: Before compleling section below shaded areo READ LEGAL WARNING on reverse side of this page. ODpI of L 8 t c. PHYSICIAN: Complete Physician's Report ach ro tort of O 1 Top Pon- wbm I . P I gl Tal where designs nd submit to Depart•t moot of labor& Industries, Attention: Acc nt Report, Clmnu Section, Olympia, Wa.9 4. Detach the Phyby physician (ion's Copy (3rd copy) for your files and promptly ma I the balance of the form to the employer this includes I Bon- porlLan suhmwed ?.: 3 the bottom portion of the Original and all of the 2nd copy,) ( j by Bmplaylr Ln --------------- f o EMPLOYER'S COPY IoJ`. oevr, CIFLABOR& SSECTI TYPE OR PRINT IN INK - REPORT y OLYMPIA, WA. WA. 9050E WILL BE MICROFILMED. 0 ACCIDENT REPORT ' LNO QtAl NI Mq[RI 0 SAE RE , COMF'ENSABEE MNUMBFN ROV TIN fMP CON FRM, ' 1 N 1 ?CJ Q 0... r S7Ar S D If x AD)/ s)arus DAIf out .? En.... x4walocar oN vcNpm cw MfKAM NIx cK. DICH crass Corvr iw ALL QUESTIONS BELOW MUST BE ANSWERED OR THERE MAY BE A DELAY IN PAYMENT OF BENEFITS. 1 INJURED WORKER: PLEASE ANSWER AM,.D NJU eDE M -1 v DnIE /, rnfPNONt-MITIR v ALL QUESTIONS IN THIS SECTION (FLI i ?YN NK/ MA GAxDDRESS Ff ?•?J ?7/IJAIf TIP CODE ?"" ?V ?11D+/ // RL air 50C Pl Sf<URHY)IUMBFN r/ •J,J JL (?IOR. '/crn>r Gt?.?.Sfir'ErJgn1 .?.?3_J S-5/?-9.5?`Pa,`°tL =' I?,+ RES DENCE ADDRESS IFDii(4FNI THA BOVf Tv BSTAI ;? 'Y: IIPCODf DAIFOi ACC U[NI o NOURACC TE TOCCURRED HNIIOURS OB 111E WNN IIJiUFED sfK DA' OFBRIr G n'?/'/9,/HnI wflcw uv(onmavw ILD I Y ??J 1 G fDATf RET R E°IOWORIL, Fs0 WERE YOU IONG YOUR EMPEOVER'S U BS IF 01HFR - y InCLCDNr, At TIME AC -.1.10 CIDENT PRFMIS HOW MANY NOW LONG HA O VE vE5 NO OCCUR? WOF O4KER5 YOU WORKED fO / 1 fM F4SRUSINES HAMEON E UNTI FpNY iH SFMPEOYfRi ??G'1-"1-r S 4kraDDRESS iiT PHaNNUMBfR ?,° r fMROYFR SBUS NESS ISIAIE OR NATUNE OFI SS OU LCCN IItR CC DI O FD 7.4 'r 'NAS HEAC<DENr IN YOUR OP r10N YES HO OU R[PORiEDACCONI TO 11 Uk1OYfR OWiroMREPORt[D: (NAME EFL (T UU fiM MANY BY WAY BY YOUR SOMEONE A (4I OvEDEMHOY[Ri IF 7 F.?Fa ae6e9VV Fa,g ,yam y . ""YFR WAS NOI ur 1 NOif ED THE5M1FDATE Wilt YOU RECEIVE Ya >v B110W rKruoto y ASTHEACCDfN7 GNTREASON SALARY iROM " rv IV HORR 4lR OAY ' PER WFfIL00'u' PERMON -R P4 ACCDENI FUMY. STAINAG FYW NE."TWEREsIRDCK, F %OYFRi G J E'IVUh MACHINERY WAS NVOlVFO r ME MACN NI AND 1 11E CON. ERE YOU L FIWG. PUII NG PUSHNG OR fA4RY1NGi C u % vV 9 ^ i .n6 s Q ?C',e /,A , ?? f? Ats gtiID PE DESCR Bf7ASINDO0450R t000N5 AND LD,AST v /1JLi ,l?r •?DAy?E(JAN- ,' OBJECT STRUCK SHOULD BE NAMED NPNFC UI OLVI ti ORIAE p', c d CAS TO \ \ _ G)?e., Lf \ C 1?O•.-.,? f G_ FSFa50NAl FMPEOYMENI?DO YOU WORK .Y l.U rU lJ I? I r]tjj h ,J-} MOPt )HAN aDHWRS PR WEfKia 1' C ?i //l /s,E1/'I EDQ its crvE TOiAIHRS. R _nK, _ GIVE NAM A BIRTH DATES OF YOUR CHILDREN DER 18 SUPP TE BY YOU roDAY DDAT - •, ?? '? NAMFy IQ uT!?N RFIAHO?Nu IP BUTHDAT NAME ?Jy F,a P IFDNCRCfDANDYWHAVFMNORCN IURfN YJPM TA A )C^ R I" I An NfxtBT;U1rNOREE MY PHISIC, BOW TAI A.' COPY OF THE COU4 ORDER 5-'ND LEGAL CU510D AN OF Npu CYO O DSCLOSF O E DEPARM"'Ll OF OR AND FWORK 'S SIINAT RE) ,. SUCH iN IDRFN. AlSp GIVE PRfS[NTADORi550F SUrrl CUSTODIAN. 'TP gS.RANY MEDI RECORDS OR`OTHER FORMAr ON REGARDING TREATMENT «r E1 NAME Or SPOUSE AT NFURr IVOUf[D.GIV[F rvAI DE D F AVE 4EA ial D DlfGAI (WORKER'S 511117 A.Pi A,Q TIME OFj L WAKII-NREVERSF _ R um E-+ ) S Df CUTI-AL CCPY. e PHYSIC AN'S REPORT °^ O Rs INI HSTORrK SUnnaNI nND NCS PaN Y. No F s HASEIF START HERE Irr4f OR-NI N NKL _2 79 *Fi I Eo nY piJroERil FOR na limbs -,ham oadwa Psi-TORSMl ,OG-TONP x ;i;,o;i (,t while on the job with air saw; a limb came down, striking patient ANSWERS -, RECORDED over left causing in j! }7. To THESE eyebrow, i?''.AEA` M I YES No QUESTIONS Cr X E wl Tr S NO ,.- n MANDATORY,[' 'n X {N SAGN05FUi?'? ,,_ OR., Yf^RDRO 1DLr v un rNDrNGS rR °[ H FSCR 9!D> Y's TO THSNFURYE of i NO ' VsON IDAGN0551KDA COCtI WOtg1H11 DUE IM-Y, 1 X yy ESTIMATED TIME LOSS . ¢. a TWO CM.. - LEIS 8YS8?W f `FFf? G OSrK L IRfATM?CFN?7?R ATION Obi y 'S C DUE TO INJURYop DAs I - " y Examination, treatment; wound washed, sutured and IATI H SCAN NNPHoNFNr aro Y. rr. s DOCTOR; TEARALONOPERFORAIIONJ CLAIMS 5ECTION, OLYMPIA, wA.. 9050,1 EMPLOYER EMgnr SU`'NAMI MA N,.uro4u-i START HERE JwHnr,Effi (4fEEn4y 1Rnffn??._?.o1iLt liO4. IMnnu 4's un.AlKxr lDnEkun rr wt«A-K-;•'fs? -- ?... ••?• NA.N TUF.11`nnn n Yl1 ut •f CUR IY InrMMR s« ++rrr,. vras larnH 111E OTNAIUL, OIL - IMPEOY , Rif NLONFNUMBr4 IrIA•E{LX(b>nlKRrl - 8 - 5 gJ+? E.. naYN5 L-UORS)RMUCT n sMRIrK)xn°' 3 _90 N I ION nN auLie OvIR IS F I 1 IxN s 1 1 4 60-01 2 cv uul NrD 1T- w .. .. ., .... : + y .r ,,, A MIA, pp , TL 3A1w 4nd ?s •l ?efte onCOnmty Off. ' 111 mhvw-..K.R1aEU_ NS H „Nr)R H T ANA1 X D i A i rAI I ryOVIL Kr W x I . TUE. -n.rrur v IEF?4. 1 p.??{T, D T 5 n0 II I ('Ip N r13 Ib m ou 1E its N?`o IBS <x..) P'eb 2 _-ter .L 3QY ?r)2-2 T9 2 Jr39 r. I? ENa <w seroF ANY -.ITT., T ? .t30_ l I IMry . xtr. No time loss II % n R 1 A f Y ?[ E f1 VRWIIr•:,rD S wAlr•IICI .v1U TIS rF ICRM ArCKKN11 LT i?W _. --. x.. A ln r,??.1MNOH11NNOrlO'r 1 EA. l fK. !E[ r+ YrO)r lu )pP) ARIDr Ub IMryUrF1 rAll M r arN..r :.R .. IvAV v i x Af . frAN [rHsnn r ? 131 LY Kn? f: 1 L_ r , M1 ? r{ k, ?/ t CEO= ''N r Mir WASHINGTON PUBLIC EMPLOYEES' USE R BD. RwLIREMENT SYSTEM U RWCyPS?p EMR x,r °a... .... E?vIPLOYEE'S PLOVER _ PERMANENT RECORD USE POR xo Y r^ wL p^an+c. xe°ea TO BE COMPLETED BY ALL EMPLOYEES dj?}I RET. BD. USE ? n ^ 'I IN ELIGIBLE POSITIONS .o aw ..... PI°ose TYR, or Print With P- _ A CONDITION OF MY EMPLOYMENT UNDER THE REQUIREMENTS AS OF THE WASHINGTON ??e5 • Z PUBLIC EMPLOYEES' RETIREMENT SYSTEM, I SUBMIT THE FOLLOWING. ?.. O a, a. x... , .?n.r x,x cool ON) ,?, oZ ,? o Naa. nn+rw rt . sY L'1 c? JN G + ... P1 H _ L- + n 1 '1? ?,' 0 fJ CD n /?uG Q lICN 174- "" AaJ°y t ! I r W ?a _- P d h Z.N I;r. T 1 ri .,Ip „ T; .1 1 1- w- LY , ' / ~ I ^ STATEMENT OF REEMPLOYMENT I WAS PREVIOUSLYA MEMBER OF •THE WASH:, INGTON PUBLIC 6EMPLOYEES' RETIREMENT SYSTEM UNTIL I SEPARATED ^EMPLOYMENT - ?..e 'WITH THE FOLLOWING EMPLOYER / X .0 -5- No ,I FOR THE PURPOSE OF DISBURSING ANY ACCUMULATED CONTRIBUTIONS STANDING TO MY CREDIT IN THE EMPLOYEES' SAVINGS +}`f FUND IN THE EVENT OF MY DEATH PRIOR TO RETIREMENT, I HEREBY DESIGNATE THE FOLLOWING' BENEFICIARY 'f w ? ? .. a +ooa. wwxa c,ar x,^e ... o.asa I+xcwoa .. ? ' c D s' - - I OR, IF E PERSON, SO DESIGNATED, PREDECEASES ME, 1 HEREBY NOMINATE THE FOLLOWING BENEFICARY, OR BENEFICIARIES, TO SHARE A;Dx^HARF ^A(lIo'KE, OR TO 1-THE T SURVIVOR. o°naas ?+xcauoa :i. cooa+.. L r w D SS- ?9H9 .p -, .. ` •'i I HEREBY RESERVE THE RIGHT TO CHANGE THE BENEFICIARY, OR BENEFICIARIES, AT ANY TIME BY FILING WRITTEN NOTICE OF SUCH m'i CHANGE. DULY ACKNOWLEDGED, WITH THE RETIREMENT BOARD. ??ItiYN +' I I HEREBY CERTIFY THAT ALL OF THE INFORMATION WHICH I HAVE ENTERED ON THIS RECORD FORM ARE TRUE AND COMPLETE. ':•'Z+ ?onw.°.. or a. ao.aa u.. or ....... . LL ° ..W 9 s.F. 5361-A (REY. 12 71) STATE OF WASH[ TON - E OYMENT SECURITY DEPARTMENT NOTICE TO EMPLOYER i APPLICANT'S NAME SSA NO. - ?O (LAST) (FIRST) (MIDDLE INITIAL) ADDRESS DATE Of ADDL. REPORT J {L=t4..i9 _ N0. STREET O RURAL ROUTE CITY ?'3^ ZIP CODE LAST DAY O' MY EMPLOYMENT WAS ?? ^ .197 AS A LOCAL OFFICE NO.Aay_? _B.Y.E. { EMPLOYEE MY EARNINGS(eEFORE DEDUCTIONS) WERE$ FOR FOR THE CALENDAR WEEK ENDING ?V 9?NUMBER ( 4 _ I AM UNEMPLOYED BECAUSE OF: LACK OF ''WORK OTHER ? (EXPLAIN) BUSINESS NAME AND ADDRESS OF MY UST EMPLOYER &L APPLIC S ST ATURE - Co INS RUCTIONS TO EMPLOYER THE ABOVE NAMED INDIVIDUAL HAS REOPENED HISCLAIM FOR UNEMPLOYMENT BENEFITS NAMING YOU AS HIS LAST EMPLOYER. PLEASE COMPLETE THE REVERSE SIDE OF THIS FORM AND RETURN IT AS SOON AS POSSIBLE OR NO LATER THAN TEN (10) DAYS FROM The U.S. Supreme Court has held that once a decision is made allowing benefits, the claimant is entitled to the prompt payment of benefits even though the employer appeals the decision. To insure proper determination of eligibility, please furnish this Department with a detailed factual statement of the separation. If the cause of unemployment is other than "Lack of Work" and you wish to be present when the applicant is interviewed regarding the separation, check appropriate block on reverse side, and you will be informed of the time and place of interview. Your cooperation may help to prevent improper payments of benefits to be charged to your account. EMPLOYER COPY - RETAIN AS YOUR RECORD (SEE REVERSE SIDE) r¢ . rl -A AOh :)WcL s,(ep 06 ueyl aloes Iol lief Au noo a ue A d yl ul luawuosudlm Aq Io OSZt ueyl aAow Aou OZq ueyl ssal lou lO oul) a Aq p payslun eq. pegs pue Ioawapslw a to All! 11 4s b(oldwo s,llun SulAoldwa wo, uol e? cE([ BulAOldu a yens Aq uewielo lyauaq ayl uanl8 of Alequoo s ) l sly 10 0-14 ayl )e 1001a41 lualle JO u p n 1 luawlreda0 a O lyauaq a to asneo ayl of 8ulweUad luawlledeo AT ! a In l ll I nS 1u0wAoldw3 ayl of uo k llew OI u1 9ulAldons j alayl s ua8e 3o s,ju dwelo k slun x.aZO !31111 aNY 34n1YN01a> S3OIA08d A118 f103S 1N3WAO ldW3 Ol 0NIl.V138 SMV'I d0 osfr 89£po '4seM 'puaswlox.',jOd AS ye'OS M08 asnOT44ano0 S8380ov AINO Ad03 6A1 Ht1 T]j a0 '}dLa "00 "S3©P W813 40 3WVN 83H10 3Hl N8TT13H 3SV3ld 6T H Et ,OR ONIIIVW 40 31.0 AdO3 83AOldW3 'AO1dW3 8nO NI ION SVM 1NV3llddV ? ---(31V0) NO )MOM Ol 03N8n138 ;SVH 1Vn01A10Nl 3H1 ? 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