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D TMENT.OF RETIREMENT SYSTE(q
Public Employees' Retirement System
" Final Compensation Report #
"Compensation Earnable" in Final Two Years of Employment
NAroE. ACKERMAN, ALVIN R *STATEMENT OF WRITTEN LABOR
AGREEMENT COVERING THIS _
SSAL: b39-14-Ub96 DEPT: 2209J1 EMPLOYEE:
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• RUN UI.TL: 09/30/86 DATE SIGNED ,037 13744,
T=RMIIUATION DATL: EXPIRATION DATE '
CERTIFIED BY
Hours Dollars
1. Amount of accrued vacation time 154 1734.09,
paid at retirement.
4 -2. Amount of accrued sick leave paid ff
at retirement. 163 1835.38
3. Amount of other earnable compensation
paid at retirement, i.e., retroactive rj
pay, severance pay, overtime pay,
clothing allowance, housing allowance,
etc. 0 0
?'...,r NOTE: We can use only that annual leave, sick leave, etc., earned in the
1-i-nal two years of employment for the Average Final Compensation
Purposes.
You must, nevertheless, transmit contributions,on the total amount paid at
--retirement. Sick leave cash outs are not to be reported for state, school
district, or higher education employees: -
Hours Dollars 8 Payoff
4. Amount of vacation time accrued
in final two years and paid at 154 :1734.04 1008 '
retirement.
a. Accrual rate per month 10 hrs.
b. Hourly rate of pay 11:26
5. Amount of sick leave accrued
in final two years and paid at
retirement 48 540.48 258
.
8 firs.,
a. Accrual rate per month /
b. Hourly rate of pay 11.26
6. Amount of other earnable compensation kl,H
accrued in final two years and paidA
at retirement (see number 3 above). 0 0 dy??
L " IF THERE IS A WRITTEN LABOR AGREEMENT, EMPLOYER MUST SUPPLY DRS WITH A COPY.
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HIGHEST CO CUTIVE TWENTY-FOUR MONTHS' MPENS
T 9
A
ION
Please indicate compensation by the calendar Month (first of the month
through the end of the month) in which it was earned.
Month/ Hours Includable Month/ Hours Includable
Year Worked Compensation Year Worked Compensation
10/84 184 $ 2035.01 10/85 184 2131.84
11/84 176 2045.36. 11/85 .168 2302.99
?
1'2/64 176 2234.02 12/85 176
2164.99 ; , ra
1/85. 189 2157.41 1/86 184 2133.32
2/85 l60 :1898.35 2/86 160
1911.45
3/85 168 1951,68 3/86 168' 1928.63 r
4/85 176 2041.76 4/66 176 2027.18
`5/85 164 2131.84 5/86 176 1864.56
6/85 160 ,1861,60 6/86 168 1884.12
7/85 184 2131.84 7/86 184 2135:97
8/85 176 2041.76 8/86 168
1965.02 ;•
9//85 168 1'951;68 9/86 176 5611.18,'
:- `-1_-- Total of Com ensatlon Listed Above 52 54 3. 56
------------
Yes No
1. Does your Agency report on a calendar month?
2. Does your agen
Gy use lag pay?
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3. Does your agency uae pay periods?
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4. If other than aboVey please explain.
i
A
PLEASE RETURN AS BOON AS POSSIBLE TO EXPEDITE MEMBER'S RETIREMENT
Return to:
Department of Retirement Systems Certified by
1025 East Union
Olympia, WA 98504 Agency
Phone No. (206) 753-5283
SCAN 234-5283 6,1,1-FrL-_r"qJ' /O d
Telephone Number) (Date)
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.,,r-.. 116 ALIMENT OF RETIREMENT SYSTEM
'. Public Employees' Retirement System b
Final Com
ensation R
ort '
p
ep
"Compensation Earnable" in Final Two Years of Employment ?SE1 hs
t
li *STATEMENT OF WRITTEN LABOR
AGREEMENT COVERING THIS
EMPLOYEE:
DATE SIGNED
EXPIRATION DATE
-
G?C/E??/Mwn CERTIFIED BY d
,
.
A Hours Dollars
1. Amount of accrued vacation time
paid at retirement. / /73
3
2. Amount of accrued sick leave paid
at retirement. s
3. Amount of other earnable compensation
a'
' paid at retirement, i.e., retroactive
;
. pay, severance pay, overtime pay,
N
k clothing allowance, housing allowance,
etc.
r NOTE: We can use only that annual leave, sick leave, etc., earned in the
dal two years of employment for the Average Final Compensation
ur
oses
p
p
.
You must, nevertheless, transmit contributions on the total amount paid at
q retirement. Sick leave cash outs are not to be reported for state, school
district, or higher education employees. a
Hours Dollars 8 Payoff , ss
n 4. Amount of vacation time accrued
in final two years and paid at
retirement. /OD%
a. Accrual rate per month /QAI-) '
'
b. Hourly rate of pay //, 2-6 ti
5. Amount of sick leave accrued
;a in final two years and paid at
retirement.
a. Accrual rate per month
b. Hourly rate of pay
6. Amount of other earnable compensation
accrued in final two years and paid
t at retirement (see number 3 above).
4+ ?~
{ * IF THERE IS A WRITTEN LABOR AGREEMENT, EMPLOYER MUST SUPPLY DRS WITH A COPY
.
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HIGHEST CO .. CUTIVE. TWENTY-FOUR MONTHS'MPENSAT
'
'
5i
r ION
Please indicate compensation by the calendar month (first of the month
through the end of the month) in which it was earned. '
Month/ Hours Includable
Year Worked Compensation
Month/
Year
Hours
Worked
Includable
Co
1
ov, mpensation
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o?,3pa•49
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? o7a 34,6 z 'y ?? /y6 arG , 9 ?"?
' ??s? /6d /69Q,3S1 ?? a/33.3y ,
' to ? 386 /G Q r
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776 '11A?
76 //
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/76 A) 76 5
Total of.Compensation Listed 'Above
-------------------------------------
-
$
----- -
---------- -- -------
-=-?=-
-
S
1. Does your agency report on a calendar
month? Is
_s
No
j 2. Does your agency use lag pay? ?
3. Does your agency use pay periods? ? r,.
4. If other than above, please explain. x '
****#####**#t###*t*#***#***#t#t*******t**#t*#**#t***#t*t#t***t**#t*t*#t**#****
PLEASE RETURN AS SOON AS POSSIBLE TO EXPEDITE MEMBER'S RETIREMENT
*t***###*t**t#***###**##t****#t****t**t*#*#tt#****##t*#***#t*#t*##*#**#***#t*t
Return to:
Department of Retirement Systems Certified by -
1025 East Union rc:,
Olympia, WA 98504
Phone No. (206) 753-5283 Agency
SCAN 234-5283
Telephone Number) (Date)
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JEFFERSON COUNTY COMMISSIONERS
A.M. O'Meara B.G. Brown Carroll M. Mercor
CHAIRMAN MEMBER MEMBER - f II
Jefferson County Department of Public Works
COURTHOUSE
W
PORT TOWNSEND, WASHINGTON 98368 -
s
Milton L. Sonstrom, DIRECTOR OF PUBLIC WORKS a r?i.?r:IF
'.
June 16, 1980
ur To: Alvin Ackerman '77
o?
From: M. L. Sanstrom, P. IE kkk?????
Director of Public Wor s'
Subject: Demotion to Maintenance Truck Driver
Your performance as a supervisor in the Quilcene area has been
below the requirements of the department. There have been com-
plaints from local residents concerning the need of maintenance
on roads in your area. There has been obvious lack of direction
in the work being done, and lack of aggressive leadership needed
for this job. You will be expected to do your daily work in a
cooperative and productive manner.
Your former' maintenance truck driver position becomes effective
July 1', 1980.
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FOR `"°`" WASHIN TON PUBLit
R Er. USE BO. RET QEMENT SY h
u h.
FOR rv„ . °. E lOYEE'S? vyt
Fi
USE SEE T-S
F EM- PERMANENT RECORD - '
. .
FApiar?
'IT" 1A
g.U
rP FOR r rx ^L ... . u[vaex TO BE COMPLETED By ALL EMPLOYEES
FIST. DO.
S USE p n[w [vo 'I IN ELIGIBLE POSITIONS •S ((i `?'"=I
Y "[x Please TYR. or Print With Pon yI` -
`t F AS A CONDITION OF MY EMPLOYMENT UNDER THE REQUIREMENTS OF THE WASHINGTON U
.)c PUBLIC EMPLOYEES' RETIREMENT SYSTEM 1 SUBMIT THE FOLLOWING:
.a R.fSa T R ?K?4Y? O'.
IwQ I Q T Nwv[ vrnsr n,ue vr°°[e rv,ve v,i°en rv,ve sac r^. -U.-
_ a „Cr ° xr" [ °r , LnV N e x +, ,rw+ , 5- /
IY °
j? x r, 3 i9z P - i;TFR 44o pSINGLE oWIDOWED
PAR r PS i R /N N ? ? a,
16/ _ .CSD
41 6 0, P -c
O :. r c i av ° v s orvr c.+:°" All
s,nx+eo airion n,r.[
rox.?.
tr9, Z `r "" °P 'u^"[ n° STATEMENT OF REEMPLOYMENT: I WAS PREVIOUSLY A MEMBER OF THE WASH
fuaa mf INGTON PUBLIC EMPLOYEES' RETIREMENT SYSTEM UNTIL I SEPARATED EMPLOYMENT
WITH THE FOLLOWING EMPLOYER: - 5'
_ - - - - - - - - - - - - - xcvroua [uxw[cn v,x"+ °" o .
?`W "e n+ urrona neruno u'
J',- ?Y QNO
a? " C)) e tt `??
FOR THE PURPOSE OF DISBURSING ANY ACCUMULATED CONTRIBUTIONS STANDING TO MY CREDIT IN THE EMPLOYEES' SAVINGS 2
A. FUND IN THE EVENT OF MY DEATH PRIOR TO RETIREMENT, 1 HEREBY DESIGNATE THE FOLLOWING BENEFICIARY:
L?C.f'ER/YlA l3exa/2 Oui[cE/yE °?y.
I? OR. IF THE PERSON, 50 DESIGNATED. PREDECEASES ME, 1 HEREBY NOMINATE THE FOLLOWING BENEFICIARY. OR BENEFICIARIES TO
3,F' -q^ 3L w 1C, w?rFi<' "HARE AND
low
SHARE ALIKE. OR i0 TL1E SURVIVOR: '
oor.[ n,v[ uar
5T 6,#/A 1,1c,{'ERM4
?, n (1 . n c n". _ _ _ _
9 P ?? y G
- -- 9 s 7
4,64 F / /YI u E L c F E q u R `- 7 / °f
TAo NR W,iDI'Yi'sioW
CtiRf ?S O.R6, r
?,Q _Na_G1L /o_ is
9 730 ??
W I HEREBY RESERVE THE RIGHT TO CHANGE THE BENEFICIARY, OR BENEFICIARIES, Ai ANY TIME BY FILING WRITTEN NOTICE OF SUCH
m CHANCE, DULY ACKNOWLEDGED, WITH THE RETIREMENT BOARD.
I HEREBY CERTIFY THAT All OF THE INFORMATION WHICH I HAVE ENTERED ON THIS RECORD FORM ARE TRUE AND COMPLETE.
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INSTRUCTIONS FOR COMPLETING EMPLOYEE'S PERMANENT RECORD (S.F. 7646)
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.. Membership for all employees eligible under the provision of the
Washington Public Employee ' Retirement System Act is mandatory. Asa
co dition of employment, the a ploy,,. s required t furnish carte.,
information to the Retirement Board w thin few days of his employment.
This is accomplished through entries ,.do o ,what termed the
Employees permanent Record. As see" s thenr record , completed t
Is ironsmitted to the Retirement 0oardaccompanlerl by. v copy of the
employee's birth certlBmta.
ELECTIVE OFFICIALS he,e the option of applying for membership
and t h accepted by acHO, of the Retirement Board. Where on elective
oR'< I ises such option, a letter of application to the Retirement
Board should accompany the completed Employee's Permanent Record.
r ere c
ORIGINAL MEMBERS who have and...d s o to an employ under
coverage of the Retirement System prior to October 1, 1947 should report
such service by letter requesting forms (R09) to be used for confirmation
of such service.
If credit ( WAR SERVICE Is claimed, such claim should be made 'n
writing accompanied by a photostatic copy of discharge papers o public et'ramont plan of which yo amber o ro stablishing
the right to rec.vo benefits from, or Fran ewlvch you araralreody receiving
benefit,
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SECTION C. Be( re cam lei n Sect on C 't should be noted the
p g
Ret rement All provides that In the event of the death of a member
Prior to retirement, 'the amount of the a ,mutated contributions standing
to his credit in the employees savings fund, at the time of his death,
shall be paid to such person onopersons having an insurable Interest
In his Ile, as he shnll have m nated by written designation duly
cured nd fled with the retirement board, or if there be no such
designated person ar persons, than to his legal representatives:'
A person having an u
r ble Interest' is darned a e having
interest the preservation of the life of the a bet such as that of
a person closely rotated by law or blood. Blood relations would be
such as child, po..nt, sister, brother, etc
Do not nominate a person whose relationship Is only that of
'fir end' unless you can clearly establish that such person has a lawful
and substantial economic Into- in having your Iifu, health, and bodily ,F'
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record, which should be forwarded to the Ret rement Board to safety coot rued, as distinguished from ' terest which would arise
become Part of the member's permanent record on file. only by, or be enhanced in valise by your death. P
service $fi5
Information supplied by the employee is strictly confidential and is The State of Washington has e. stenos what is popularly known
for the of the Retirement Board in establishing his membership status. a a Communi ly Property law. If you are marred, you spouse has r
`
an interest In your earnings, and h s or her Interest would be recognized '
SECTION A En•cr your lull name In Section A. Do not use 'nir'ah• before payment could be made to any other beneficiary you might ,.
-A d vvll?hon must give her full maiden name as well as bar nom note.
married name. Enter your Social Security Number. The documentary
,vidence submitted with the Employee's Permanent Record must support The Retirement Board should be promptly notified of any change
F
.he birth date entered In Section A. of address or or any change f status such as death or divorce of the Y
SECTION b B. Enter the name of your present employer through Torn nominated beneficiary or benefiLries. F[Lt .
you or. , mittinq the Employees Permanent Record, local on of
the SECTION D Your i gnotum must be subscribed to before a witness.
employ t nd the day upon which your present mployment began. State the address at which your mail is race' d. (Advise Ills Retirement
Enter the title of the position you hold as it actually appears on the Board of any subsequent thong of that actress.) Upon completion of
pay oil If you r Ise being employd
e by another pol c agency, the Employees Permanent Record it should be given to your Personnel
enter "the name of (hot agency. Enter the na r nabmes of any Officer or designated official for rronsm teal to the Retirement Board. ??? ?(^' C ? s
BIRTH EVIDENCE
Any member. born subsequent to 1910 should furnish a copy of
his birth earflRmta. A member born prior m 1910 may have trouble
in securing a birth certificate. and If he unable to secure such ,
document there h a wide fold of o,Im, documents which a -ptubl,
as proof of birthdate. Legible photostatic copies of such documents
will be acceptable.
II you a e female and birth evidence is in your MAIDEN NAME,
..;..PLEASE IDENTIFY It with the name under which you are carried on your
employer's payroll. CHILDHOOD DOCUMENTS-One only required Any record from your
childhood Is regarded as fairly comparable to a birth rnn,fcaro. Som. of
Ihef. are.
i BuP,ithe .r C.nfl-flon Record from a church showing blrthdate.
2. R,,.rd .1 birth Irmn o (..fly Bible. II such record r fumish.d
o-cspy of all entries horn the Bibla.racord should be carolled by a
Notary Public.
0. Sch.. ago '*'.to. This could be a school cerhfcme showing
tint you were of a certain age on a designated date.
4, U. S. Cantu d On ly sl Irom a cans,, token in your child.
`hswd. On your ,q..,, we Turn h o loan to ,nnd ih. U. S Census
Bursa, This will big back their record of any census in which they
an find you h,red.
5. There a. many other childhood record, that a1e suitable. For
ale. you may hove n book Ihm was giver to you s childhood
birllmp,do, gilt and which has o -ml- of binhdme on the flyleaf. You
could have this flyleaf photographed and the photographer make
affidavit describing die book and i's appnro.1 age. One member subn
miffed a pholostonc enPbY of n nnw pa In which he as mentioned
as a child, nge 14. In or. account of n "Id-t.
ADULT DOCUMENTS-Two or more required.
I. Notarised aMd.vll by sa ember of the Immediate family who
Is older than the member and in a position to knew definite details.
o.g., father, mother, older sister or brother, etc.
2. C,0111cotn of Attract Services record. (Foreign Service Is acceptable.)
3. Montag. record, only If It shows age.
4. U. S. Co.,., Record.
5. PossporM1 and Noluralhalion <arlificale,. WARNING-It is a felony
for any parson to pr nl, photograph, make or e.ocute r in ny an e
e to be printed , pha,ographod, made r e.eculed w.lhout lawful
amt 11, any print or impression of these documents. I( It 1, dashed
I. so the Inlonnanon contained theeon to verify birlhdote, pertinent
e.plonallan of the pr edura to be (allowed c n I,. secured by wring
to the Retirement Board, However, you can hav a Notary Public, Ml ulitster,
or
any public official ..amine rile document and make an oBidavi, that
ho had soon Coriificotn or Passport No .............. .._.., Issued by IName
of Court or Justice Deparlmen,l, on (Date of Issuance), and that your
age was stmad on the, to be (age).
?0a 6µ Lodge ?o nhlp cords or letter from lodges certifying to your
hen tined
you
7 Insurance poll clog, if Your age It shown.
8. Drivers licence, er hunting glans., if you age is shown, only if
,his document is 10 Y-s old.
9. Valor's R,gitlra,i.n Cartigcat,. Only if your age is shown thereon.
10. Oth,r recuments. If the case Is to unusual as to make it
Impossible to Ivtnish any of the above requirements, Inquir a, in their
regard should be d'recled to tl.e Retirement Board
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