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HomeMy WebLinkAboutReel_0024D (6) ~ --. .., , .- lHTI ~ -~~ -~- -.. ilii1......~.___~,~~ -".1:'_-"""""l , .' '..... . ..........':< ~. .' >/'.' . ..'.. :". :',: . . '.. '.. .:.<...,.::.. ::,..-. .' ..... . .< " ~ ; , .. ; . ... . ., ,........, . >. :'., "::1' >.. .' .......................... . '. ........ ..... : . :.. .:.. '..- .::. ..:....... .........:..... ....-.....-..... , ,'.:", .' .'. ..... ........ ',' ;... . ...... . .<:. ~ ....:. '., :'>"1~ ..... '>.; s, F. No. 76019-(Rev. 8-73) -, ..... " . . . -,', .J......... , '. : ".: ..... :. ,. .. .':' ....,. . ..;:..:.' " .....' --1. .......:..>......... . 'I .:' '.' '.. ....:. . . .; .... .., ,.:,c . J '::..' :":'~1{~~tl ,: ....., ." ........... . .... ....,:..: '.' ....:. . . . '.," ..-' ',> . .'-' .... . .'" . .. .. ." .. > .' . ...... . . . .... . .... C' . . ...... .... i. . . '. . ":" '. .. ,; <:: FOR Govt. UnIt Dept, ~ EM- ~ PL8Ji:ER I I . fidel' to your Transmittal Report or Deduc- tions, Part B. Write In dCpllrtmcnt numbers. WASIIINGTON PUBLIC EMPLOYEE'S RETIRE1\-IENT .El\1 NOTICE OF SEPARATION ~~p.~1!~1r....3Q....;!,~............... Date I SOCIAL SECURITY NUMBER 53~ I 50 I 3:XlO : ..:.' :. : ~ :: .. . . .... . >.c, ~ THE FOLLOWING EMPLOYEE HAS SEPARATED FROM THE PAYROLL OF THIS AGENCY FJrst Name Middle Name I SeparaUon Date eg Resigned J\.lc.n Scott JuJ::f 31. J.<Jfo 0 Retired ENTER GROSS AMOUNTS PAID BELOW 0 Deceased Amount MR~~~r\~dbC 0 Ineligible Position o Granted Leave of Absence .. Last Name , .' '.' .c Salary .00 without pay until...................... Date : .:.. . .' .... '. GROSS PAID FOR: Terminal Lenve Sick Leave '. ".'. Other .!!'.e..r..r.e.;;:~.c>,tl...q~~~;r...1.I:I:~~..p.!?J?t..:................... Employer Agency .' .<.. k ...h........sjGn;;iiir~..~Tper.s;;nn~'j'(ir.ii.ayr;;ii"o.iiiccj............... .:, INSTRUCTIONS: ~f,~,~rS~ ;-;.~:II?h':n~'\I~~~IOa~l~~~e.nd~ll"~~:SeJ~'j~rl6~ ~;~r~er~ft~~1 ~~~~cgor:;~uAo b~R~\~;l(y~tll:~~~lI?cT;.cr, ...e-, ~ ..; i; '".. . ..' ." ....:. ..,.......... .' ...:' . . .......... ............ ..' . ." ':.' .......' ....,...... '., .':'" .:..:.....:...... ,.". . '.. :/...... ". .... <.:...... ..::." ;:'. .., '. ,.;;,< '..,;.::..:'" ....... .....: :'::..... . ." ....'...': - . .: :," .:. ;...:' .... .~" . .-'. . ,. : ': , ' . : ....::.... "':. .... . ; ...... ID .. . ..: .-' :;: ....i. :: .. .' '.':'(' ........:... .:. ..' :..... . .' .. ...' i: ..... ....., ....:. : '.. .::. . ........ ". :. .::.c.' .....>... ,'.: . '. .,-:..... .<:> .. .' ... . ." ,..... .'. '., ..:. ':.' i .'. ...... .,: ..... . ..... .::: .'. .' i. .' .... . '.' :" '. .11 'II .,11 ;11 >1 . .." :."'.' :: , . '.' t' ;..i '. " .... . I.', ",: '... : ~ . : ". "L ~ ~ ,..... .' ,,;~:jj .'. ; : ..c '< :\': :;',:; 1~F~~f~ c':'<;;; .:.:-.:, " 'II~\'. r-~ !!!!!t~~~w GROSS PAID FOR: Salary Terminal Leave Sick Leave Other ..... .P: ,."".It ~~ ""- ~:: ...-- .... - '''.--.".,- -"-'- ~.. _Jl,. ___~TI .....l..~ . . .--,.".:' ..' '. .' . . . .... .' >.. .' ':'c. . . : '.' ".': ':'. .' , .' ' , .;' ,',:"'" .,.: "~c. . ..' . ...... . ..:' . '. ..':<:,;:'. . . . .:' ': : '..t.. .. :.. '. ';.. ::'."" 6:'!!~76.'''''''''D;;io'''''''''''''''''''''''''''' :; ':. . , ' .' I SOCIAL SECURITY NUMBER ..,.,,(::::::'-.: 531 150 ~ :':.' :,: .... .::' :..- . . :.., .::' ENTER GROSS AMOUNTS PAID. BELOW Amount Month to be Reported .: ':': < :-." ...... ;. :.' '" .." . ,'. .. .... . ' <:...,' '.:: I:. ..... ". ...... .....; .;.... '.' .....: ,'. ,..' .' " .,::.'..' :.'.' '. :.......: '.. > ::...::~'r-' .. ' .,; , ,', ..' ...... '.: . /" ,', ..:: ...... .' .. .':'., '. " .. "": ."'. .... .'. ..... . ..........:. ,>, . c.:'..'!..., . :: ";'.'. :.:". ." .. . ,);W....... .'. '" . ..;J~\~~%;r; s. F. No.16~!I-(ncv. 8.73) WASHINGTON ...;. '(.,>' ~~': 'I GoV<. Unit Dep,." PUBLIC E~IPLOYEE'S RETIREMENT S.E~I .. . PLaYER I I I NOTICE OF SEPARATION /, Reier t~S:;'ur Trnnsmlttal Report of Dcduc. Uons, PlIrt B, Write In department numbers. 'c' THE FOLLOWING EMPLOYEE HAS SEPARATEU FROM THE PAYROLL OF THIS AGENCY . . ~= ;:'me s::eNnme I ~C;;:'O~;;6 0 Resigned o Retired o Deceased o Ineligible Position 28 Granted Leave of Absence 388.08 r.~.32 ~. 19'1\S ~. 19'16 '.:...... .....~!~~~..~~..~..~.!................ly'{):i Employer Agency . ," . .:>.' .....;,...,!.:...._...................!....................:;:........".................... 'i. '.' Slgnnturc of Personnel or Payroll Officer without pay until...................... Date '. '. ...e. ' '. INSTRUCTIONS: ~~~Vfarll~ ~~~~\,:n~I~~~10~l~~lees"d~I{I~~3~cd~IJ~W~~ ~;~r~er~l~~~ ~~c"~~~\O b~g~~~\v~"l:;~~a?ctp:,cr, .. .' . . .'. . "':, '.' ': .':.' . . "'. ." ....:... . '. .' . . ." '. :": . , ,". .. ' '.. '" '., ... . . .",' . .. ", ....... .:. ..:: . . .'. .'. ,':.' .'.. . .....:: ;. . '.' .' " .. ", .' .'.':' -: .: . .. . ..: "','., ...~..'.:: . ..' ..... .: . :. · . ."i....:.. .'.: ,......:.'i:::,;: : ..,...'.:,::::::I'!': .'. '..:: .: . ",:~ ". --1.. -:1 .' .:.' : '.", '.: . ." :; '.. . .... 'e '. .. . '.' .< .. .' ..<.'. ..... .. 'i,., ':: .":, ..' . "'::.' '.... ,.'- . ...:",: '.. . ,:..:, . . '. ,/ . ...... . .., ...... . .'.; ..... . " . " ..... ';'.' ,; /.;'., '. ..:..... ,,'.'. '.." , .. '...:" . >' '.' ..... ...... . : ';'..' '.- ~....' '.:. ... :'. . '''. :,,:, .:'.:....... . " :'."," '.' .. ,". .: " : "'.:;,;','.',1:,,, . ..... x: '. . '; .' ., .';. ,; .: :Y :;. ;:; ,.'.. :l-,. :;:; .', ------."'.,,,"..,"'., '., .3:lR... ___ ~!- ^- rt~~ll III .------, 'T"'q _J:!!l~..J.JP'j~,~w.<<n1I, . R ~" .......,..-=.. ........~~-V- ~'"qI_ _ -.n::~ NIIPM _1IlIlIIII _ ....JlIllilr ~,,:.. .:.~~ I-~~'~~.r-:":,~~ . . '.: '-, .' . '. ", ::,' ", ' ". ' I:' " ., _' " ,'" .'. ' "." , . ~--- ~' f.'iiii.;;...,:"...,:-...,....,' ":"'''''' "', ," " . -, :'.-'~ .' ' _'~"''.,._I '.:' l,,.t.;~ ...~... ~..:.... " ,>>,' ',' ."p', .~ ;:"',... r '~'~~"'" ,.... -v !l!l1Il r- -'iIl!f.__.........,.,. ......... ..,.!I!IIlIml!! ':.'.. ". .,..',' :.. 'i.:.. . . ~! r'Ill'" "JT'S- ~.. .. '--:~ :_'';"...!~.~~:--.: . '-:.... '~'~"1-. ~ :..+_, .:::":"' , :~.,":'"..J......, :1, -~ ...J:III .. .' . ...... . . : .'..' :.......,:: ',' ',' ..' . . ". .... .. .... ': . :'. ..... ..' ~.. .'.'. .' ..' '." .' .:",. .'. . '.. ....... ..", .... ',". . "-. .,d<,. .'. c; '.' .... .... . c' '.. . '.' ..,:d ,'..' . ": "'.'. '."'".,.; .... .. . . '. , ". .', c . :.'. ..: .. ,. ..'..'.... c. ...... .:......,.,:......"..': c:-- FOR EM_ PL.OYER USE AGENCY NO. ,- EMPLOYEE'S PERMANENT' RECORD WASHINGTON PUBLIC EMPLOYEES' RETIREMENT SYSTEM Pd. Box 91B Olympja~ashin9ton 98504 " FOR RET. SD. USE liiE:! TRANSMITT"L REPORT OF DEDUCTIONS_PART B ENTRY DATE /D NO. I "", QRIO, MC/oCUlt/l o Nt.Wr.UIoUIIiR (To be completed by all employees In eligible posillon5 whether 'or, ,0 lint empfoymcnf or 0 reemployment.' IMPORTANT: S~o instructions on hack: AS A CONDITION OF MY EMPLOYMENT UNDER THE REQUIREMENTS OF THE WASHINGTON PUBLIC, EMPLOYEeS' RETIREMENT SYSTEM,' I SUBMIT THE FOLLOWINGr A COPY OF SOCIAL .. SECURITY CARD MUST BE ATTACHED ~M) AwW . .s, C1 /13/4a ;ACE OF~. '" . ' 'I~C: I;A~~r:;,::.~u~ DIVORCED rOte.T, I Ou.>>J.s~ J WA..I jo F 0 WIDOWED 0 SINOLE l ~31 i '50 i a9~ I I 10CIAI- IECUI'I'~Y NO. JE~G~ GwAJr'{ p...eUc.\..U~,Qs ..... '~~"~T~'V$2-J'R>er lOW/JSJ;:NI). WA-;C783b8 .' O....TIl 01' I"'I"LOY"'EH~. ON ClJI'IRIH~ ,"O"TION '. "'OIi~HLY .....L.l'Iy . ". . STATEMENT OF REEMPLOYMENT: I SEPARATED EMPlOYMENT. ON '., '.. MILITARY SERVICE I WAS PREVIOUSLY A MEMBER OF THE WASHINGTON PU8l1C EMPLOYEES' RETlREME.Nl SYSTEM"UNTIL >:'.,: CONTRIBUTIONS REFUNDED p.".' D NO . ~..:..~..,~., ~EM8ER ..~~...~t>~~~~~:.~A~.~~.'.~~..~~~~...~~.~...~~~~.~~!~~...~.~~~~;~~~~~:;.~~~~~.~::'.: PRIOR SERVICE, (suvrcll ;;;;;1:. OC:TO.U l~4'J '.' ,'. DATES-FROM . TO... AGENCY --.-. FOR THE PUR~05E OF DISBURSING ANY ACCUMULATED CONTRIBUTJONS'STANDINO' TO MY CRf.D1T IN THE "EMPLOYEES' 'SAVIN~:~ ,:":,;,", FUND IN THE EVENT OF MY DEATH PRIOR TO RETIREMENT, I HEREBY DESIGNATE THE FOLLOWING 8ENEFICIARYl' .'" ",' Sce Instru<:lIons. on Bock (C), . .', " ,,' . ~."' "t:1::~ '~,w I~'~;:"'~T forZT~~:=~' ';/;;;4"" ~H~RI; ~~~'PsE:1~~'A~~E~E~~G~~T~~E Ps~~~~~;~s M~, I HEREBY NOMINATE THE FOLLOWING BENEFICIARY, OR BENEFICIARIES, TO" . ~;~~~""t:1~'0~"~Ar-J '~~~~:~A-~~ DS111~/'1~" '.' ... '.... '\ '.' . .. C,. .'. I I HERE6V RESERVE THE RIGHT TO CHANGE THE BENEFICIARY, OR I3fNEFICIAR1ES, AT AhJY TIME ,8Y FIUNC WRITTEN NOTICE OF S'UCH (tlANGE, DULY ACKNOWlEDCfD, WITH THE RETIREMENT BOA liD. . , I HEREBY, CERTIFY THAT All OF THE INFORMATION WHICH I HAVE ENTERED ON tHIS FORM IS TRUE AND COMPLETE,. .,ON....TlJ"r o. _ IUIPLO'l'IE:& WITNu.rD ., I'UIONNCt. ---+ 0' ,.A'tI'lOLI.. OI'I'ICC" -------------------- ---------------- . . : - - - - - - - -.. - - .';;Iti'rol'l-":-o7.0.-NO,- - - - - - -.. - -.. -.. . . . ~ ~- . R. 8.1&46. -e-. ." ;C:' ! ~... ,\ , '.\. :: . , 'i~.. C. " :.. , :> '. ".' \.'. ". . <. ....., '.'. ".,/. '. ,"': ":.: ....... .': :.. ." .........i." '. """", ,,'. ',i. ::.: ..... .' . :,,:.. ......." '. . ...' .'.'. " ; ,.... "', ,c': :. -:. . "::: ..... '. -::.<':.:'. ....,. .:" ...... C . '.' .... . ". .' .....:. . . ::. ',' :..' . : .,' ',"''' . . c :':.' '. .:..." ." '. >'.".' ; .~ -,-,-,-"'".~ ,- r-lf ,IT': _,--- ~'__~, \".~.....~..,.~~__.:.~,.... ~~, I,: ., ," _j~~~ ~.'.~ :......._::;'-'-d-,.... "" .,,,_._... -v. ___ _, - , ".T9_ -- .",,-,'1-, ;..', . "-." " '. -'" ' '-~"""':l" :.-:'~ ,-', ""'r' ~ 'i,':: .,:'-.",;,: ,'::',: ":,,',,') ~.."...'..' .. ., '., ---. -- .. .. - ,.., ,,"- ~ "'.',-,"','" ;i,>",,"" FOR EM, PL.OY ER USE WASHINGTON PUBLIC EMPLOYEES' RETIREMENT SYSTEM E1tPLOYEE'S PERMANENT RECORD FOR RET. SD, USE TO BE COMPLETED BY ALL EMPLOYEES 'IIN ELIGIBLE POSITIONS .;;3 Plol;ue TYPIJ or Prlnt With Pan .. '" ASA CONDITION OF MY EMPLOYMENT UNDER THE REQUIREMENTS OF THE WASHINGTON PUBLIC EMPLOYEES' RETIREMENT SYSTEM, I SUBMIT THE FOLLOWING, SOCI"1.. seCURITV NO, LA.T tM"'~ F'''ST N"""'!; "'IOOl-IiIIA"!: ",AIPl:NHA"'1: :50 , CARMAN ALAt-~ 5(011 I NOl\\E E:>~ I 3908 , D..TI[ Q~ BIRTH ~"o'" ,,"n, P OR T I,'" I "^",,, "'''' 9/ 13/4B Q'NNSEND)WN_ ~: !II"""" o SINGI..r;; o WIDOWED o DIVORCED "m" o.",om . .j E F F E RS 0 N C.o I~;~:~~~~-f;;~;~'f pATI:5T,,"Tro ~OSITION TITLe EN6LNEER\NC":1 DEPT-' 4- )-7Z- ENE!_ AIDE WASI-\. 'A.'" 111.10 Efo.PL.DYCO ".,. 'I'OI,ITICI\1.. SUIIOIV,IIION, l.OC;...TlON O"TI:$T""TEO POSITION TnLII!: '.. r..... A ...1l....u:I'l 0" TIll: "OlLOWINC STATEMENT OF REEMPLOYMENT: I WAS PREVIOUSLY A MEMBER OF THE WASH. I'la:TrllCMCNT "L...N Oil PL.JIoNS INGTON PUBLIC EMPLOYEES' RETIREMENT SYSTEM UNTIL I SEPARATED EMPLOYMENT WITH THE FOllOWING EMPLOYER, - - - - - - - - - - - - - - ,."a:VIOUS r::Mrlo>,a:II sa:r"'''^TrON D"Te: I 00",""","0", "~""O'o o YES 0, NO fOR THE PURPOSE OF DISBURSING ANY ACCUMULATED CONTRIBUTIONS STANDING TO MY CREDIT IN THE EMPLOYEES' SAVINGS FUND IN THE EVENT Of MY DEATH PRIOR TO RETIREMENT, I HEREBY DESIGNATE THE FOlLOWING BENEFICIARYI """ST ""''''I!'. "'laDll!"'''''''!: .....T....."I': "CD4.5b1aC:ljlj ;,7;11' srl!" IICL"'TrONSH,r DJIoTI!C"BIIlTl-i KAREN MARIE CARMAN .1"0= TOW,",Se.>!P1 WA9>+ WIFE '3/15/4~ ""8 '2."- e OR, IF THE PERSON, SO DESIGNATED, PREDECEASES ME, I HEREBY NOMINATE THE FOllOWING BENEFICIARY, OR BENEFICIARIES, TO .;HARE AND SHARE ALIKE, OR TO THE SURVIVOR: (I) ""ST .........I! ...rOt:lLtu.....rr L...lIT"'.....!!: ..oo..,;u l'''C:lllt:l('trpCOO("1 J<RIST/N MARie C"RM~ t+C=L.D I\.J TR.\.ls'r e." P(~(/~>O" :0/'l\.\.~11-l- 8;\'5/71 Be:-L.D v.J m~ 1'~R..<t ~r2S Ly~~ Gl-...........J II.> Ie. CL....'\ '( s,.... l'Al2etJr-S 4(a.T' T lrWr-lS15r-lb WA-!.~. :, ;\<; :11 I HHEny RFSn:VE THE RIGHT 10 CHANGE THE BENrFrCIAl1Y, OR IltNEflCIAI1IE$, AT ANY TIME BY FIliNG WRITTEN NOTICE OF SUCH CHANGe. DULY ACKNOWLEOGro, WITH THE RETIREMENT BOARD. .....(;' J HEREBY CERTIfY tHAT AU OF THE INrORMATlON WHICH I HAVE ENTEREO ON THIS RECORD FO~M ARE TRUE AND COMPLETE. ,'i: -;"';j.\(M-6 (~vw^-- '"J"'''''rv,,~ nf WITtO.... :.' _Pll..", lI"C~f,/Cl' 'tl.. CaUl', p..rt 403 "U'I ST 4-/ 5 /72- ERTlOwl-JS,tSrvD) WASH ~B~b'O ". __.._ '_~ _. ,,,,,I_~l.', I " I. ""'r,' :c.' __,'_'. ~ FOR EM. PLOYER USE EMPLOYEE'S PERM~1'{JENT RECORD . FOR RET. BO. USE TO BE COMPLETED BY ALL EMPLOYEES IN ELIGIBLE POSITIONS : ',;;...j.X:.;. " .,,::,~,. Ploo.. Ty". or PrInt Wilh Pon THE WASHINGTON Z :,'l g~ ~~: CARMAN .2.;::. OATJ; 01' IIII1TM ''ll~, Sept. 13, 1948 CI),:,::":,, 10CI"'1. .ICUIIIT.,. NO. Alan Scott none 531 i 50 Port To-..msend, Washing- ii! M ton OF MAMRIIlD 0 SINGLE I'"J;SII:NT 1:I''~1001'1''' Je~~erson County Engineers' Off. Courthouse; Port Townsend, Wa. I.C~~;thouse Port Townsend, Wa 2/15/72 I "N ALIO IU'~l.o",.g .... I~OI.IT'c",1. IU.OIYIIIO"I " , I A" A "'.,...111 01' TI1&" I'OIoLOWINO IIJ;TUIII:NINT ~1o"'H 011 "I....N. .. FOR THE PURPOSE OF DISBlIRSING ANY ACCUMULATED CONTRIBUTIONS STANDING TO MY CREDIT IN THE EMPLOYEES' SAVINGS FUND)N THE EVENT OF MY DEATH PRIOR TO RETIREMENT, I HEREBY REVOKE ANY PREVIOUS DESIGNATION OF BENEFICIARY WHICH MAY BE INCONSISTENT AND HEREBY DESIGNATE THE FOLLOWING BENEFICIARY. OR BENEFICIARIES. TO SHARE AND SHARE ALIKE, OR TO THE SURVIVORI _; Karen Marie CARMAN "'OOllU~ tlNCIoUOII: 'ZII' COOII:', Port Townsend, Wi~e 2909 Gise St'Washin ton 8 6 2909 Gise ST. Port Townsend, Wa. 98368 March 15, 1949 Kristin Marie CARMAN OR, IF THE PERSON, OR PERSONS. SO DESIGNATED. PREDECEASES ME. I HEREBY NOMINATE THE FOLLOWING BENEFICIARY, OR BENE. FlCIARIES, TO SHARE AND SHARE AliKE, OR TO THE SURVIVORI daughte "'OOllnl tlNCI.UOI 'ZI~ COOI." 1616 Clay st. father Jan. Gerald ly1e CARMAN Port Townsend Wa. 8 68 1616 Clay at. Feb. Clara Louise CARMIu~ Port Townsend Wa. n 68 Mother ~5i:- .."...", <::E' , "" >.2.:~: u- C')-', ~~ '" ... I HEREBY RESERVE THE RIGHT TO CHANGE THE BENEFICIARY, OR BENEFICIARIES, AT ANY TIME OY FILING WRITTEN NOTICE OF SUOf CHANGE. OUL If ACKNOWLEDGED, WITH THE RETIREMENT BOARD. I HEREBY CERTIFY THAT All OF THE INFORMATION WHICH I UAVE ENTERED ON THIS RECORD FORM IS TRUE ANO COMPLETE. . ........ 0 'OM... ~ c~~ z o ;:::- 0<5 c:.. .9 ;:: Jie Alnn S. Carman 2909 Gioe Street \::;;:.~ ~, "'S 0<:::"i\-<\ FEB. 11.5, 1972