Input Form B - Corrections Officer Retirement Plan
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1
2EIN:_____________
CORRECTIONS OFFICER RETIREMENT PLAN
INPUT FORM B
(Please fill in all of the information on this form. If not applicable, please indicate.)
INPUT SHEET FOR (select one):
__ SURVIVING SPOUSE
Today’s Date:_______________
__ GUARDIAN OF DECEDENT’S DEPENDENT CHILDREN
Date of Death:______________
__ DESIGNATED BENEFICIARY
Was member Retired at Date of Death? Y N
__ PERSONAL REPRESENTATIVE OF DECEDENT’S ESTATE
PERSONAL INFORMATION OF DECEDENT
Name:_______________________________________________________
_____________________________
First
Middle
Last
Social Security Number
Sex (circle)
M
F
Date of Birth:_____________________________
Marital Status (circle)
M
S
APPLICANT INFORMATION
Name:_______________________________________________________
_____________________________
First
Middle
Last
Social Security Number
Date of Birth:_____________________________
Date of Marriage (if Surviving Spouse): ________________
ADDRESS AND TELEPHONE NUMBER OF APPLICANT MEMBER
Address:____________________________________________________________________________________
Street
Apt.
City
State
Zio Code
Phone: Home (___)__
____________
Cell (
)
Work (___)__________________
Personal Email _________________________________________
IF BENEFICIARY OR REPRESENTATIVE, SIGN AT BOTTOM. IF SURVIVING SPOUSE OR GUARDIAN, CONTINUE
DEPENDENT CHILDREN OF DECEDENT++
DECENDENT EMPLOYMENT INFORMATION
Date of Birth
Disabled?
Current Employer:_____ADC____________________
Name
Y**
N
Service From _______________ To ______________
Y
N
Local Board Name:_____CORP___________________
Y
N
APPLICANT PAYMENT INFORMATION
Payment Method (circle):
Check
Direct Deposit
Payable to: ___________________________________
Federal Tax (circle): Single/Married
Exemptions:____
State Tax (circle): 0.8% 1.3
% 1.8% 2.7% 3.6% 4.2%
5.1%
APPLICANT DIRECT DEPOSIT INFORMATION
Name of Financial Institution:_________________________________
Phone Number:__________________
Address: ________________________________________________
ABA Routing No.:________________
Street
City
State
Zip Code
Account Type (circle one):
Checking
Savings
Account No.:____________________
BENEFICIARY (of the APPLICANT)
Primary Beneficiary:____________________________________________
Date of Birth:__________________________ Social Security Number:__________________________________
Relationship(s):____________________________________ Phone Number_____________________________
Address:___________________________________________________________________________________
Secondary Beneficiary:____________________________________________
Date of Birth:___________________________ Social Security Number:__________________________________
Relationship(s):_____________________________________ Phone Number_____________________________
Address:____________________________________________________________________________________
Secondary Beneficiary:____________________________________________
Date of Birth:___________________________ Social Security Number:__________________________________
Relationship(s):_____________________________________ Phone Number_____________________________
Address:____________________________________________________________________________________
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