HomeMy WebLinkAboutReel_0024C (38)
a?
ffflll a D.?i _.
? Xa S
TF-
}
.r?vwrraa?.K
e?
v
N
s?
? 1
?
?
?
?
'
1
l
ll
11 1
- 1 X
I ' 1 o
F
k ? ! I! ?' 1 ? ?
J
d7
'
? f i{? 1
f t ? ?
J
S
F
a ' f 1
y?
A
, ? 'I313 R( ` l?
T
IMPORTANT .
Before completing Sectio below it should be poled the Retirement A
•ovides that in the event of the death of
a member
rior to
ti
t
' f
•
p
re
remen
,
the amount of the accumulated contributios standing to his credit in the employees'
n
savings fund, at the time of his death, shall be paid to such person or persons, having an insurable interest In his life, as
he shall have nominated by written designation duly executed and filed with the retirement board, or If there be no such ,
designated person or persons, then to his legal representatives." '--
M
A person having an "insurable interest" is defined as one having Interest In the preservation of the life of the i
,
member such as that of a person closely related by law or blood. Blaod relations would be such as child, parent,
sister, brother, etc.
Do not nominate a person whose r
l
ti
hi
I
"
"
e
a
ons
s only that of a
p
friend
unless you can clearly establish that such
person has a lawful and substantial economic interest In having your life, health, and bodily safely continued
,
as distinguished from an interest which would arise only by, or be enhanced in value by your death. If You
desire to nominate more than one
erson to
h
ll
p
s
are equa
y in the refund of your accumulated contributions, dnly
complete designation No. 2 of Section C.
The State of Washington has in existence what is popularly known as a Community Property law. If you are _
married, your spouse has an interest In your earnings, and his or her interest would be recognized before payment could J
be made to any other beneficiary you might nominate.
.The Retirement Board should be promptly notified of any change of address or of any change of status such as 'i
depth or divorce of the nominated beneficiary or beneficiaries.
...................................................................................................................... ........ related to me as....................................
(Noma In [ulh (birth date) "."""'"
whose address Is............ ............ .......................... ...................................... ........................... related to me as................................................
(Namo !n full) (birth tlalo)
whose address Is
.............................................................................................................
......................
3 hereby reserve the right to change the beneficiaror beneficiaries at any time by filing written notice of
such change, duly acknowledged, w(th the Retirement Beard .
S i
GENERAL INFORMATION REGARDING THE EMPLOYEE'S
'
i PERMANENT RECORD FORM
All statements in this Permanent Record Form constitute a record of
h
t
e Washington Public Employees' Retirement System and will be used ..
in determining the eligibility or ineligibility for membership and in
establishing the rights
privileges and benefit
f
l
,
s o
emp
oyees participating
_ in the system, Information supplied by the employee is to be considered . ,?
" strictly confidential and is for the use of the Retirement Board only.
e
Q
ti
h
l
@?
'r -
? u
s
ons s
ou
d be answered to the best of the employee's knowledge,
i
f
. n
ormation and belief and in respect to RCW 41.40.100:
- :'
' "Any person who shall knowingly make any false state- -
. .
.. ments, or shall falsify or permit to be falsified any record or -
e records of this Retirement System in any attempt to defraud
the Retirement System as a result of such act, shall be guilty
0
of a gross misdemeanor."
- Further: The attention of all employers and employees is called to -- `
t RCW 41.40.130, which reads as follows: i'
"Within thirty (30) days after his employment or his accep-
tance into membership by action of the Retirement Board each
l 4
emp
oyee, appointive or elective official shall submit to the
Retirement Board a statement of his name, sex, title, compensa-
tion, duties, date of birth, and length of service as an employee
or appointive or elective official, and such other Information
as the Retirement Board shall require. Each employee becorn Y
Amok
ing an original member shall file a detailed statement of all his
prior service as an employee and shall furnish such other facts
as the Retirement Board may require for the proper operation
of the Retirement System. Compliance with the provisions set
forth in this section shall be considered to be a condition of
employment, and failure by an employee to comply may result
- in separation from service." i
v' This form should be filled out in Ink or on a typewriter. It is important
that the printed instructions furnished you for completing this form be care-
i
y r;? fully studied before making any entries.
?
rJ
1
f
?
q
at F I ,
'r ,.?s
I
,p
,
#: 1
l
? :r ?
S
??
FM ,f r
_
Y
rrQQ
S 1j 1 :-Tt,di >d a !: a f
y k'» i ` + ai„?'ki.ss?all,": 4t"9.A'^ ??`irr?77 ]try ' wt" 1Y'?i
'11 W 717
r .r'+e tti't 1 e ? i N'? h: >t r 1 'i r {,1 r t ?
Wr7??t 216 dc.. L
? ? if 1 I 1 ?r' ti ? ?.
r
y 1 ? i
71 ? 4 f ?(r`?? 5 { 5 +?f ?1.. ti 1rJ
1 i''t .l a
.t
I+. .'NAM
?bn4YY
i +J ?1
1 1F -?