Member Actuarial Information Form - State Of Delaware
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1
2Form No. P-1 (5/15)
Office of Pensions
Email: pensionoffice@state.de.us
McArdle Building
860 Silver Lake Blvd, Suite 1
Toll Free Number
Dover, DE 19904-2402
Outside State of Delaware
Telephone: (302) 739 - 4208
1 - 800 - 722 – 7300
STATE OF DELAWARE
MEMBER ACTUARIAL INFORMATION
Reset Form
PERSONAL DATA:
To be completed by Member (Please Print)
1. _____________________________________________________________________________________ 2. Soc. Sec. No.: _____________________________
(Last Name)
(First Name)
(M.I.)
(Maiden Name)
3. Address: _____________________________________________________________________________ 4. Telephone No.: _____________________________
(Number)
(Street)
(City)
(State)
(Zip Code)
5. Date of Birth: _____________________
6. Gender:
Male
Female
7. Marital Status:
Married
Civil Union
Single
(Month / Day / Year)
(Choose One)
(Choose One)
8. Organization: ________________________________________________________ Department ID: ________________________________________________
9. Pension Plan: (Check One):
State Employees’:
State Police:
Judiciary:
Legislative:
C/M Police/Fire:
C/M General:
(LOSAP) Fire:
Port:
10. Effective Date of Hire with Present Organization: ______________________________________
11. Current Annual Salary: ________________
12. Have you previously been a member of any State of Delaware State Sponsored Pension Plan: Yes
No
If YES, complete list below:
(INCLUDE LEAVES OF ABSENCE
PRIOR SERVICE CLAIMED
AND INDICATE REASON)
FROM
THROUGH
PERIOD COVERED
NAME OF ORGANIZATION
MONTH
YEAR
MONTH
YEAR
YEARS
MONTHS
TOTAL PRIOR SERVICE CLAIMED
(ADD)
13. (a) Did you serve in the Armed Forces of the United States:
Yes
No
(b) If (a) is YES, show total Active Military Service:
FROM ________________________
TO _________________________
TOTAL CREDIT ________________________
(c) Did you begin a full-time vocational or professional training course within 5 years of your discharge and become a State employee
within 5 years after the completion of that training: Yes
No
(d) If (c) is YES, show full-time vocational or professional training course dates, and date degree, diploma, or certificate granted:
FROM ________________________
TO _________________________
DATE OF DEGREE _________________________
14. Have you ever rendered full-time service in professional educational employment or other full-time employment for another State or the
Federal Government, a county or municipality of the State of Delaware, a political subdivision of another State, or in an accredited private
school or college:
Yes
No
If YES, complete list below:
FROM
THROUGH
PERIOD COVERED
NAME OF ORGANIZATION
MONTH
YEAR
MONTH
YEAR
YEARS
MONTHS
15. Are you eligible for benefits as a result of any service listed in No. 14 above:
Yes
No
DEPENDENT DATA
:
(This information must be filled out if you are married or in a civil union.)
16. Name of Spouse: _____________________________________________________________________________________ Gender:
Male
Female
(Last Name)
(First Name)
(M.I.)
(Maiden Name)
_______________________________________________________________________________________ Telephone No.: __________________________
(Street Address)
(City)
(State)
(Zip)
Date of Birth: ____________________
Soc. Sec. No.: _________________________
Date of Marriage/Civil Union: ______________________
(Month/Day/Year)
(Month/Day/Year)
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