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2008 Federal Witholding Tax Rate Calculator document sample
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Benefits Calculator Import Page
Version 13.00
First Name *
Last Name * 1
Address 1 (Apt) * 2
Address 2 (Street) * 3
City * 4
State * 5
Zip Code * 6
Phone * 7
Date of Ordination * 8
Social Security # * 9
Date of Birth * 10
Gender * 11
Marital Status * 12
Credentials * 13
Date of Marriage *
Church Service #
Hospital Service #
Canada Service #
DC Plan Service #
Benefit Rate Factor #
Spouse Name *
Spouse SS# *
Spouse Date of Birth *
Email Address *
Final Termination Date *
Original Date of Hire *
Benefits Calculator Information (for letters)
Individual preparing this estimate or application should enter this information.
Name:
Title:
Organization:
Phone #:
E-mail Address:
Fax:
Seventh-day Adventist Retirement Plan Application
North American Division - Defined Benefit Plan
12501 Old Columbia Pike
Silver Spring, MD 20904 Version 13.00
Retiree Name: DOB 1/0/1900 0
Address: Gender: 0 000-00-0000
Address: Marital Status: 0 Spouse DOB: 1/0/1900
City, State, Zip Credential: 0 Divorce Date (if any)
Home Phone: - Date of Marriage 1/0/1900 Benefit Type:
*
Cell Phone: Est. Church Years 0.00 Pension Code
Conference Membership: Est. Hospital Years 0.00 Date of Termination: 1/0/1900
Date of Ordination Est. Canadian Yrs 0.00 Retirement Date
SS#: 000-00-0000 Est. DC years 0.00 Normal Retirement Date #N/A
Est. BRFactor 0.0000 Medicare Eligible Date 1/1/1965
E-Mail Address: - Service Type: (H, C, M) C
Joint & Survivor
If married, do you waive the Joint & Survivor benefit and select the Single Life benefit? (Y or N) If not married, enter N.
If Married, how many of your pre-2000 church (not hospital) years of service credit were you married to current spouse?
Spouse Allowance
Are you applying for a Spouse Allowance? (Y or N) Appears Ineligible for Church
Is your spouse receiving benefits from an Adventist Retirement Plan? (Y or N)
Will your spouse qualify for benefits from an Adventist Retirement Plan in the future? (Y or N)
Is your spouse receiving retirement benefits from ANY employer including non-denominational? (Y or N)
If "Y", what is the monthly amount? $0.00
Will spouse qualify for benefits from ANY Retirement Plan in the future (including non-denominational)? (Y or N)
If "Y", when?
Did or will your spouse receive access to an employer-provided lump sum retirement benefit from any employer? (Y or N)
Amount $0.00
Date Accessible
Organization providing Spouse's retirement benefit.
How many DC years shown above are after 2014? No DC Years 0.00
Other
Are you applying for Parsonage Allowance Exclusion?
Are you applying for Healthcare Assistance? (Y or N) Not Eligible
Are you requesting Direct Deposit of your Monthly Benefit? (Y or N)
Are you applying for the one-time lump sum Retirement Allowance? (Y or N)
Are you a Qualifying Independent Transfer Employee?
Are you a Career Completion Option Employee? (Y or N)
Are you an ordained Minister? (Y or N)
Do you have qualifying Military Service? (Y or N)
Hospital Service Section
If Married, how many pre-1992 hospital years of service credit was employee married to current spouse?
How many hospital years did employee work AFTER 1991?
In addition to Hospital service, how many pre-1992 years of Church and/or Canadian Service?(for APS & HSP SA eligibility)
Was employee married to current spouse for ALL of 1991?
Was employee married to current spouse as of 12/31/1991?
Was employee either Currently Employed or Term/Vested as of 12/31/91?
Was Employee Currently Employed on 12/31/91? (y/n)
We have reviewed the information in this application, and believe it to be accurate as presented. We understand that service credit
must be certified by the Retirement Plan before this application is final. We confirm that all following signatures are legitimate.
Employing Organization Union
Employer Contact <Phone <E-Mail
Employer Officer <Phone <E-Mail
Union Officer <Phone <E-Mail
Date:
Employer Officer Sign:
Date:
Retiree Signature:
Witness Signature: Name > Date:
(Employer or Notary) Title >
Disclosures: 000-00-0000 Page 2
Joint & Survivor Waiver Not Required
We understand that in signing this waiver, we are permanently forfeiting benefits provided by the Joint & Survivor benefit including:
a. Healthcare assistance for retiree's spouse including Medicare Part B reimbursement, and/or Accrued Pension Supplement.
b. Survivor benefits for retiree's spouse should the retiree pre-decease the spouse.
c. Death benefit at the death of the spouse.
We understand that signing this waiver is an irrevocable action. No employer or plan officer has urged us to sign this waiver, and we have
signed it voluntarily.
Retiree Signature: Date: Spouse Signature:
Early Retirement Disclosure -- Church Plan Only NRA Table #N/A
I understand that applying for benefits commencing before my normal retirement age will result Year of Birth NRA
in a permanent 0.5% reduction in benefits for each month that I am younger than my normal 1937 65
retirement age, or for each month that my qualifying service credit is less than 40 years, 1938 65 & 2 mo's
whichever yields the greater monthly benefit. 1939 65 & 4 mo's
I also understand that if I qualify for and elect S.H.A.R.P. healthcare assistance for myself 1940 65 & 6 mo's
and/or my qualifying dependents, but am not yet Medicare age, S.H.A.R.P. will withhold a 1941 65 & 8 mo's
contribution from my pension equal to the estimated cost of providing such assistance, and will 1942 65 & 10 mo's
NOT provide an Earned Credit towards that contribution until I reach Medicare age eligibility 1943 to 1954 66
(currently age 65) unless I have 40 or more years of qualifying service credit. 1955 66 & 2 mo's
1956 66 & 4 mo's
1957 66 & 6 mo's
Requested Church Normal Ret Date 1958 66 & 8 mo's
Retirement Date: 1/0/1900 #N/A 1959 66 & 10 mo's
Retiree Signature: Date: 1960+ 67
Spouse Allowance Disclosure Not Required
We understand that the retiree's total monthly benefits may include a separate Spouse Allowance, and that the Spouse Allowance will continue
as long as the marital status of the retiree remains the same as it is on the benefit effective date. If spouse will be eligible for his/her own
employer-funded retirement benefit, the Spouse Allowance will be reduced by that benefit amount when it is received or when spouse reaches
Normal Retirement Age according to Social Security (table above), whichever comes first.
We understand that it is our responsibility to provide written notification to the retirement office should our marital status change - due to death
or divorce - or at such time as the spouse receives employer-provided benefits of his/her own from any employer, denominational or not.
In the event of such personal changes, we understand that the Spouse Allowance component of the total monthly benefit will be adjusted
according to policy. We understand that any overpayments of the Spouse Allowance will be returned to the Retirement Fund either through
direct payment or payroll deduction.
Spouse
Retiree Signature: Date: Signature:
Retirement Allowance Authorization Not Required Basic Monthly Wages, OR
We, the employer recommend that the Plan pay the Retirement Allowance Bi-Weekly Wages
indicated. We authorize the Plan to bill us for a contribution equivalent to the $0.00
amount paid. We will pay the portion of the Retirement Allowance earned after
1999 directly to the employee. Plan Provided Retirement Allowance $0.00
Sharing Church Employer: Employer Provided Retirement Allowance $0.00
Percentage other employer is responsible for: Total Retirement Allowance $0.00
Eligible for Retirement Allowance? Y or N NAD Retirement ID#
Authorizing Employer: 0 Batch Date
Authorized Signature: 0 100.00%
Retirement Allowance Election of Method of Payment - Pre 2000 Benefit Not Required
I hereby elect the following method(s) of payment for my Retirement Allowance distribution(s) from the Plan:
Name of Plan: % to be Paid Directly to Retiree: 0%
Account Number: % to be Rolled Into a Tax Deferred Plan: 100%
Address of Plan: Total (Must equal 100%) 100%
Type of Plan: TSA, IRA, Other?
Plan Contact Name &
Phone # --->
The Plan named here is an eligible individual retirement account or individual retirement annuity established in my name, or a qualified defined
contribution retirement plan or annuity plan which accepts direct rollovers. I acknowledge that all amounts paid to me from the Plan, and NOT
paid directly to a qualified tax-deferred plan are subject to a Mandatory 20% witholding for Federal Income Tax for the Pre-2000 Retirement
Allowance.
Retiree Signature: Date:
Disclosures: 000-00-0000 Page 3
Social Security Election Form (Alternate) Not Required
(For use only if the Standard Form is not applicable and attached to service record.)
I understand that I will not be eligible for Medicare based on my work as a minister. I have been informed that upon retirement my denominational health care
assistance will be calculated as if I did have Medicare coverage normally provided for Social Security participants. S.H.A.R.P., the retiree Healthcare Plan will
NOT provide coverage for healthcare expenditures usually covered by Medicare.
Retiree Signature: Date: Spouse Signature:
Memo from Employer: This Minister has been informed of the Healthcare implications of being ineligible for Medicare.
Authorized Employer Signature: Date:
Independent Transfer (ITR) Disclosure Not Required
I understand that my Retirement Healthcare plan may require coordination with my home division's Retirement Plan. I authorize the Plan to
contact my home division for purposes of such coordination. I acknowledge that if I was not employed by a participating employer as of
December 31, 1999, this Plan will only provide healthcare for NAD years of service credit, unless authorized by the home division Retirement
Plan to provide healthcare assistance based on pre-NAD years of service.
I also understand that if I qualify for pre-NAD years to be paid at NAD rates, the Plan is authorized to collect from my home division any benefits
due to me from my home division, or to reduce my benefits by the equivalent amount, at the discretion of the home division Retirement Plan.
I am attaching documentation of action by the General Conference or the North American Division attesting to the effective date of my
Independent Transfer.
Retiree Signature: Date:
Insurance Conversion Option Not Required
I understand that the NAD insurance contracts provide me with the right to continue or convert personal insurance coverages that were
provided for me or that I paid for, and have discussed these options with my employer and have taken the necessary actions. I understand that
the time window for taking such action is limited. (See Retirement checklist at: http://adventistrisk.org/downloads/checklist.doc)
Retiree Signature: Date:
Parsonage Allowance Application Not Required
I believe that I qualify for Parsonage Allowance Exclusion under Internal Revenue Code Section 107, and request that my pension income be
treated as excludible from income tax within the constraints of that section.
Ordination Date (if any)
Was Parsonage Allowance Exclusion allowed by last employer? (Y or N) Employer Signature:
Do not use this cell.
Retiree Signature: Date: Not Qualified
Military Service Disclosure Not Required
I believe that I qualify for Military Service Credit under Z 15 50 in that I served in the military, and upon discharge, within one
year was denominationally employed, or within one year I enrolled in an educational program and upon completion or
termination within one year I became denominationally employed. Attached is a copy of my induction/discharge
documentation. Up to two years of actual military service may be granted after analysis by the Retirement office. Note:
Hospital employees are only eligible for Military Service Credit if hospital service after post-military employment is continuous
and unbroken until age 65.
Retiree Signature: Date:
Inservice Distribution Disclosure Not Required
I understand that if I accept full-time denominational employment for an organization participating in the Church Retirement Plan while receiving
monthly retirement benefits from this 'frozen' DB Plan, NAD Policy requires the Plan to suspend my church-plan retirement benefits, including
healthcare if any, until such time as I terminate or reduce from full-time to part-time. I understand that the plan defines part-time as 75% or less
of full-time work expectation for my particular assignment. I accept responsibility to inform the Plan immediately if I begin such employment of
over 75% of full-time denominational employment other than on a temporary (3 months or less) basis.
Retiree Signature: Date:
Page 4 Not Required
SUPPLEMENTAL HEALTHCARE, ADVENTIST RETIREMENT PLAN
Enrollment Form for 2010
Church Service Only DOB SS#
Retiree 1/0/1900 000-00-0000
J&S Spouse 0 1/0/1900 000-00-0000
Earned Credit Eligible? Y or N n
Retiree Spouse Monthly Cost Retiree Cost Spouse Cost
Base Option (Y/N) $20 $0 $0
Dental/Vision/Hearing (Y/N) $55 $0 $0
Prescription Drugs (Y/N) $115 $0 $0
Medicare Extension (Y/N) $130 $0 $0
Total Cost $0 $0
Standard Earned Credit: $0 $0
Personal Cost per Month $0 $0
Pre-Medicare Option (Y/N) $399 $0 $0
Dependents - Name Below DOB SS#
$138 $0
$138 $0
Total Pre-Medicare Costs $0 $0
Pre-Medicare Earned Credit $0 $0
Non-Medicare Earned Credit - First Child $0
Non-Medicare Earned Credit - Second + Children $0
Personal Pre & Non Medicare Cost $0 $0
Total Personal Monthly Cost $0 $0
Monthly Payroll Withholding for S.H.A.R.P. $0
SHARP Declined? Y or N Reason for Decline?
Please enroll me in SHARP coverage as requested above.
I authorize SHARP to deduct monthly contributions as calculated by SHARP based on my requests for coverage. If my pension is inadequate
for the monthly contributions, I agree to make quarterly payments in advance.
I understand that I am limited in changing options, and that the first opportunity to make a change in coverage would normally be at the one-
time three-year anniversary of my enrollment.
I understand that there are deductibles and maximums for the options I've selected.
I understand that if I do not list my J&S Spouse above, he/she will be ineligible for any healthcare benefits until applied for during an open
enrollment, such as a ‘loss of coverage’ or the one-time three-year anniversary.
I hereby certify that children listed are my unmarried legal dependents, below age 19 and eligible to participate in SHARP. I have attached a
copy of my latest filed Form 1040 indicating dependency. I understand that my children become ineligible at either marriage or age 19,
whichever comes first, and I will inform SHARP of such an event.
I understand that Pre-Medicare or Non-Medicare cannot be cancelled until ineligibility (reaching Medicare eligibility, or for a dependent child,
marriage or age 19.)
I understand that the Pre-Medicare/Non-Medicare IP/OP plan is part of a Preferred Provider Organization (PPO). Out-of-network expenses may
be reimbursed at lower rates.
I understand that if I have not selected any options on the attached Standard Enrollment Form, the Pre-Medicare coverage, if selected, will be
limited to only in-patient and out-patient coverages provided by Pre-Medicare option as described in this booklet, and will not include
prescription drugs, dental or other coverages described in the standard SHARP options.
I understand that the calculations above are based on an estimate of my years of service, requiring final certification by the Retirement Plan
Office.
I am attaching copies of my Medicare cards showing Part B enrollment. If not yet eligible, I # Enclosed: (0,1,2) 0
agree that it is my responsibility to mail a copy to SHARP when received.
Retiree Signature: Date Signed: Effective Date:
Page 5
Hospital Lump Sum Payout Election Not Required
Hospital Years Service Credit 0.00
Single Life Benefit #DIV/0!
Not eligible for Hospital benefits. Less J&S reduction (if selected) $0.00
Spouse Allowance (if eligible) $0.00
Accrued Pension Supplement (if eligible) $0.00
Lump Sum payments can be paid to the retiree with a required 20% withholding Estimated Total Hosp Monthly Pension #DIV/0!
for Federal Income Tax, or into a tax-deferred account opened by the retiree. Estimated Lump Sum In Lieu of Pension N/A
Enter T for Taxable or D for Tax-Deferred Hospital benefit effective date 1/1/1965
Name of Plan:
Account Number:
Address of Plan: Note: The Retiree must have opened a tax-deferred
account able to accept rollovers from a 401(a) plan.
Such accounts can be opened at banks or brokerages.
Plan Contact Name &
Phone # --->
Type of Plan: TSA, IRA, Other?
I understand that these estimated benefits are subject to review by the Plan. Final calculations may results in figures that differ from above.
If I am eligible to receive monthly benefits and choose to receive the Lump Sum in Lieu of Pension instead, I hereby release my employer(s)
and the Plan from responsibility and liability for any future retirement benefits.
________________________________________________ ___________________________________________
Retiree Signature Date Spouse Signature (If Married) Date
_____________________________________________________________
Witness Signature (Last Denominational Employer or Notary Public) Date
Church Lump Sum Payout Election Not Required
Church Years Service Credit 0.00
Single Life Benefit N/A
Less Early Retirement Reduction N/A
Spouse Allowance (if eligible) N/A
Not eligible for Church benefits. Accrued Pension Supplement (if eligible) N/A
MC Part B reimbursement (if eligible) N/A
Lump Sum payments can be paid to the retiree with a required 20% withholding Transitional Enhancement (if eligible) N/A
for Federal Income Tax, or into a tax-deferred account opened by the retiree. Estimated total Church monthly pension N/A
Estimated Lump Sum in Lieu of Pension N/A
Enter T for Taxable or D for Tax-Deferred Church benefit effective date 1/0/1900
Name of Plan:
Account Number:
Note: The retiree must have opened a tax-deferred
Address of Plan:
account able to accept rollovers from a 403(b) plan.
Such accounts can be opened at banks or brokerages.
Plan Contact Name
& Phone # --->
Type of Plan: TSA, IRA, Other?
I understand that these estimated benefits are subject to review by the Plan. Final calculations may result in figures that differ from above.
________________________________________________ ___________________________________________
Retiree Signature Date Spouse Signature (If Married) Date
_____________________________________________________________
Witness Signature (Last Denominational Employer or Notary Public) Date
Page 6 Required
Withholding Certificate for Pension or Annuity
W-4P Payments 2010
Name SS# 000-00-0000
Address
1. "X" here if you do not want any federal income tax withheld from your pension or annuity. (Do not complete lines 2 or 3.)
2. Total number of allowances and marital status you are claiming for withholding from each periodic pension or annuity
payment. (You may also designate an additional dollar amount on line 3.)
Marital Status: (M or S) Note: Even if Married you can put Single for withholding at a higher rate.
3. Additional amount, if any, you want withheld from each pension or annuity payment. (NOTE: For periodic payments, you
cannot enter an amount here without entering the number (including zero) of allowances on line 2.
Your Signature: Date:
Note: An original Form W-4P along with IRS instructions can be obtained at the IRS web site: www.irs.gov/pub/irs-pdf/fw4p.pdf
Direct Deposit Authorization Not Required
I hereby authorize the Retirement Plan and the Bank of America to initiate credit entries
Tape a voided printed check or copy below. If a and to initiate, if necessary, debits and adjustments for any credit entries in error to my
check is not available, tape a bank-provided account indicated below; and the depository named below to credit and/or debit the
Direct Deposit Authorization form in the space same to such account. This authority is to remain in full force and effect until the
below. If neither is attached, this request cannot Retirement Plan has received written notification from me of its termination in such time
be honored. Please don't use staples! and in such manner as to afford the Retirement Plan and the bank a reasonable
opportunity to act.
Retiree Signature: Date:
Emeritus Ministerial/Commissioned Minister Credential
Application Letter
To:
Executive Secretary Phone: #N/A
#N/A Fax: #N/A
#N/A
#N/A #N/A
#N/A
The minister named below is retiring from our organization on the date shown below. Pursuant to the terms of NAD Working
Policy, we are requesting that you issue appropriate Emeritus Credentials effective as of the date of retirement. I hereby
certify that this minister meets the criteria of D 10 55.
Please contact this minister directly with any further questions or instructions. If you issue credentials with a picture, please
provide information. Thank you for your kind attention to this matter.
Sincerely,
Date:
0
0
Retiree Name: Current Address & Phone Retirement Address & Phone
Date of Retirement: 1/0/1900
Total Years of Service: 0.00
Current Credential: 0 -
0
Page 8
Retirement Allowance Election of Method of Payment - Post 1999 Benefit
Employee SS# 000-00-0000
I hereby elect the following method of payment for my Retirement Allowance distribution from my Employer:
Dollar Amount OR Percentage
To be Paid Directly to me: 0%
To be deposited Into my ARP Account: 0%
Estimated Total $0.00 0%
This form serves as a special Salary Reduction Agreement. I hereby authorize my employer to withhold the amount or percentage of the post-
1999 Retirement Allowance shown above from my wages at the pay period in which the post-1999 Retirement Allowance is granted, and to
deposit this amount into my Adventist Retirement Plan Account. I acknowledge that all amounts paid to me and NOT paid directly to my
Adventist Retirement Plan account are subject to tax witholding subject to my currently filed form W-4.
Retiree Signature: Date:
This form is for the Employer and need not be sent to the Retirement Plan.
Page 9
This application is NOT complete without:
Joint & Survivor Waiver Not Required
Early Retirement Disclosure #N/A
Spouse Allowance Disclosure Not Required
W-4P Required
Direct Deposit Authorization: Not Required
Retirement Allow. Authorization Not Required
Retirement Allow. Elections Not Required
S.H.A.R.P. Enrollment Not Required
Minister's S.S. Election Not Required
Independent Transfer Disclosure Not Required
ITR Action Documentation Not Required
Insurance Conversion Disclosure Not Required
Emeritus Credential App. Not Required
Military Service Disclosure Not Required
Inservice Distribution Disclosure Not Required
Application Checklist
1. All required application forms filled in and signed.
2. Service Analysis Tab entered. Hard copy of service record reconciled with eAdventist Personnel service record.
3. Entered and saved the retiree's retirement effective date in 'Retire date (US)' field under the employment tab in eAdventist before printing
4. 1st page retiree & spouse signature witnessed by employer, or notarized.
5. DC Years updated to termination date on DB Benefits tab, D7.
6. Verify estimate of Benefit Rate Factor on import sheet. If incorrect, over-ride on DB Benefits D14.
7. Include Retiree's current contact information - email, mobile phone, home phone.
8. If there is a divorced living ex-spouse, request divorce decree or QDRO from retiree to send with application.
9. This application is not complete if there are any red warnings to the right of questions that have not been dealt with.
10. Send complete package to Retirement Plan. Include:
Signed application forms
Original hard copy of service record
Printout of computerized service record signed and dated
ITR letter from GC or NAD if employee is an independent transfer
Copies of Medicare Cards for both retiree and eligible spouse if available
Copy of printed personal check for direct deposit bank
Copy of last form 1040 if child dependent healthcare application
Electronic copy of this Benefits Calculator, either by burning a cd or by uploading via eAdventist Personnel.
Military Discharge documentation if applying for Military Service Credit
Copy of diploma if applying for Graduate Study Credit
11. Inform Retiree of date you sent application package to Retirement
Retirement Benefits Calculator Version 13.00 2010
Today's Date Retiree SS# Original DOH Date of Term Pension Code Benefit Type
7/17/2010 000-00-0000 1/0/1900 0 0
Church DB Years 0.00 0.00 0.00
Pre-NAD Years for Post '77 ITR 0.00 0.00
Hospital DB Years 0.00 0.00 0.00
DC Years 0.00 0.00 0.00
Canada Years (For Pro-ration of SA & SHARP EC Only) 0.00 0.00 0.00
Spouse Shared Years, Church & Hospital 0.00 0.00 0.00
Retiree Birth Date Year/Month 1900 1 1900.08 0.00
Normal Retirement Date #N/A #N/A #N/A 0.00
Church Retirement Date (Year/Month) 1900 1 1900.08 0.00
Hospital Regular Retirement Date (Year/Month) 1965 1 1965.08
Benefit Rate Factor 0.00
Spouse Birth Date Year/Month 1900 1 1900.08
Spouse Retirement Benefits (Monthly $) $0.00
Spouse Retirement Benefits (Lump Sum $) $0.00 $0.00
Date Spouse Lump Sum Received 1900 1 1900.08
Spouse Retirement Benefit Non-Denominational? (Y or N) 0.00 Act. Ret Age Ineligible! Not yet age 59.5
Joint & Survivor or Single Life? (J or S) s Over-ride J&S%?
J&S & Age Reduction % 0% 480 Mo's < 40 Yrs
Eligible for Church Spouse Allowance?(Y or N) n #N/A Mo's < NRA
Eligible for Hospital S.A.?(Y or N) n
Male or Female (M or F) Error Pre-Ret Survivor? Early Ret Reduction Rates (CH Plan Only)
Employer DC Lump Sum - Basic & Match n Age % #N/A
Years of post-1991 hospital service? 0.00 Svc % 240.00%
Total Pre-1992 years Church (for APS & HSP SA elig only) 0.00 0.00
Was Hosp emp. married to current spouse all of 1991? 0 Employed or Term/Vested on 12/31/91? 0
Was Hosp emp. married to current spouse on 12/31/91? 0 Employed on 12/31/91? (y/n) 0
Eligible for Medicare Part B? (0,1 or 2) Ineligible 0 Over-ride SC for HC & DB Basis (Years)
Comparison of Estimated Benefits ERR Bens Church Hospital Total
Single Life Benefit #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Less J&S Reduction $0.00 $0.00
Joint & Survivor Benefit #DIV/0! #DIV/0! #DIV/0!
Sp Allowance w Spouse Reduction #N/A $0.00 $0.00 SA Unreduced
Age-Differential Spouse Allowance/% Red. #N/A $0.00 $0.00 0.00%
Monthly Benefits #DIV/0! #DIV/0!
Early Retirement Reduction #DIV/0! #N/A
Accrued Pension Supplement $0.00 $0.00 Breakdown of Church Ben's
Medicare Part B Reimbursement $0.00 #DIV/0! SLA
Monthly DB Benefits #DIV/0! #DIV/0! #DIV/0! $0.00 TE
No-Freeze Single Life Benefit $0.00 #DIV/0! Total
Less Early Retirement Red. (SL) #N/A #DIV/0! ITR Adjust
Net No-Freeze DB Single Life #N/A #DIV/0! Total J&S
Independent Transfer Employee Reduction #N/A SA
Frozen Net DB Single Life (Above) #DIV/0! #DIV/0! SA ITR Adj
Less Early Retirement Red. (SL) #N/A #N/A Total SA
DC Estimated Single Life Annuity #N/A $0.00 APS
Combined Single Life Annuity #DIV/0! #DIV/0! Total
Transitional Enhancement/Effective % $0.00 #DIV/0!
Total Monthly Benefit #DIV/0! #DIV/0! #DIV/0! (of SLA or JS)
Card File? (Y or N) Ordination Date
Membership Conference: 0
Spouse Name: 0 Spouse SS# 000-00-0000
Date of Marriage 1/0/1900 Return Copy to Employer?(Y/N) n
Contact Information Phone E-Mail Name
Retiree - 0
Primary Employer Contact - - 0 0
Employer Officer - - 0 0
Union Officer - - 0 0
Retirement Allowance Calculation
CCO Employee? (Y/N) 0
DB Years 0.00 0.00
DC Years 0.00 0.00
Current Monthly Pay, or $0.00
Current Bi-Weekly Pay $0.00 $0.00
% of Full-Time Employment 100.00%
Plan Provided Retirement Allowance $0.00 0.00 Months
Employer Provided Retirement Allowance $0.00 0.00 Months
Total Retirement Allowance $0.00 0.00 Months
Remarks:
Not Eligible for S.H.A.R.P. Less than 15 qualifying years SC.
SHARP Enrollment Form with Application? (Y or N) If "N", date sent to Retiree
SHARP Pre-MC Form with Application? (Y or N) If "N", date sent to Retiree
Declined SHARP Coverage? (Y or N) 0
Reason Declined: 0
SUPPLEMENTAL HEALTHCARE, ADVENTIST RETIREMENT PLAN
Retiree:
J&S Spouse: 0
Ineligible Earned Credit Eligible? (Y/N) n
Retiree: Spouse: Monthly Cost Retiree Cost Spouse Cost
Base Option (Y/N) 0 0 $20 $0 $0
Dental/Vision/Hearing (Y/N) 0 0 $55 $0 $0
Prescription Drugs (Y/N) 0 0 $115 $0 $0
Medicare Extension (Y/N) 0 0 $130 $0 $0
Total Cost $0 $0
Standard Earned Credit: $0 $0
Personal Cost per Month $0 $0
Pre-Medicare Option (Y/N) 0 0 $399 $0 $0
Dependent Children (Unmarried, below 19) DOB SS#
0 1/0/1900 0 $138 $0
0 1/0/1900 0 $138 $0
0 1/0/1900 0
0 1/0/1900 0
Total Pre & Non Medicare Costs $0 $0
Pre-Medicare Earned Credit $0 $0
Non-Medicare Earned Credit $0
Net Personal Pre & Non Medicare Cost $0 $0
Total Personal Monthly Cost $0 $0
Total Monthly Payroll Withholding for S.H.A.R.P. $0
Service Credit Analysis for Summary T Yrs Q Yrs BRF #DIV/0! LE Totals 0.00
Church 0.00 0.00 Included in Church Years
Hospital 0.00 0.00 Post-1991 Years 0.00
0 Canada 0.00 0.00 Version 13.00
DC 0.00 0.00
CCO? n Total 0.00 0.00 Literature Evangelists
Church Plan Hospital Plan Canadian Plan ARP YRF F/L? Fatal M or F? m
Year Total Aggregate Year
Months Hours Year Q Yrs Months Hours Year Q Yrs Month Hours Year Q Yrs Month Hours Year Q Yrs Pre-2000 Y Break? LE Hours LE YSC
1960 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1960
Convert to Months only. Full-time must be 1872+ hours.
Convert to Months only. Full-time must be 1872+ hours.
1961 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1961
1962 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1962
1963 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1963
1964 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1964
1965 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1965
1966 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1966
1967 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1967
1968 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1968
1969 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1969
1970 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1970
1971 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1971
1972 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1972
1973 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1973
1974 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1974
1975 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1975
1976 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1976
1977 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1977
1978 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1978
1979 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1979
1980 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1980
1981 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1981 0.00
1982 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1982 0.00
1983 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1983 0.00
1984 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1984 0.00
1985 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1985 0.00
1986 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1986 0.00
1987 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1987 0.00
1988 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1988 0.00
1989 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1989 0.00
1990 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1990 0.00
1991 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1991 0.00
1992 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1992 0.00
1993 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1993 0.00
1994 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1994 0.00
1995 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1995 0.00
1996 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1996 0.00
1997 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1997 0.00
1998 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1998 0.00
1999 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1999 0.00
2000 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2000 0.00
2001 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2001 0.00
2002 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2002 0.00
2003 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2003 0.00
2004 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2004 0.00
2005 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2005 0.00
2006 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2006 0.00
2007 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2007 0.00
2008 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2008 0.00
2009 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2009 0.00
2010 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2010 0.00
Total Benefit Years 0.00 0.00 Benefit Years 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Includes LE Years if any.
0
July 17, 2010
Dear Future Retiree:
This letter provides an estimate of your monthly benefits under the frozen defined benefit retirement plan. The
statement below shows estimated benefits and the basis upon which they were calculated. Please review it and
keep it where you can find it.
This is an estimate only. Actual benefits will be granted based on documented service credit and other
information at retirement.The estimate is in today's dollars, is before any tax withholding determined by IRS
tables and your W-4P and does not include the effect of a Transitional Enhancement for which you may be
eligible, but which is not calculated until your benefit effective date. Healthcare contributions may not be
estimated. After reading these materials, if you have further questions, please feel free to contact us at the e-
mail address (preferred) or phone number shown. Estimate prepared by:
0
0 E-mail address: -
0 Phone: -
0 Fax: - Version 13.00
Estimated Benefits
Estimate Based on 2010 Benefit Rates Church Hospital Total*
Years of Qualifying Service Credit 0.00 0.00 0.00
Single Life Benefit #DIV/0! #DIV/0! #DIV/0!
Less J&S Reduction (If selected) $ - $ - $ -
Spouse Allowance (If eligible) $ - $ - $ -
Early Retirement Reduction #N/A #N/A
Total Monthly Benefit #DIV/0! #DIV/0! #DIV/0!
Accrued Pension Supplement $ - $ - $ -
Plus Medicare Part B Reimbursement $ - $ -
Less S.H.A.R.P. Net Contribution (If Calculated) $ - $ -
Monthly Benefit before Tax Withholding (if any) #DIV/0! #DIV/0! #DIV/0!
Lump Sum Payout in Lieu of Pension N/A N/A
* 'Years of Qualifying Service Credit' above do not include 0 Defined Contribution
or 0 Canada Service Credit. Total years = 0 years.
One-Time Lump Sum Retirement Allowance - Plan Provided: $ -
One-Time Lump Sum Retirement Allowance - Employer Provided: $ -
Estimated Survivor Benefit, Joint & Survivor: $ - $ - $0.00
Estimated Survivor Spouse Allowance (if eligible): $ - $ - $0.00
Estimated Survivor Spouse APS (if eligible) $ - $ - $0.00
Less Survivor S.H.A.R.P. Net Contribution $ - $ - $0.00
Total Estimated Survivor Benefit $0.00 $0.00 $0.00
Estimated Death Benefit $ - $0.00
A General Explanation of Terms
Also see the "Answers to Your Questions" Booklet
Also see the "Answers to Your Questions" Booklet
1. Years of Qualifying Service Credit: These are years of service credit calculated from your service record.
Hospital years quit accruing on 12/31/1991. For most church employees, church years quit accruing on
12/31/1999. If you were eligible for and signed up for the "Career Completion Option," additional years may have
counted up to a maximum of 40 years of service credit or until 12/31/2004, whichever came first. Post-1999 church
years count only towards meeting thresholds and for healthcare, not for monthly benefits. Due to Canadian
pension laws, benefits a retiree earned based on service credit in Canada must be paid to the retiree directly from
the Canadian Retirement Plan. Those benefits are not included in this estimate.
2. Single Life Benefit: This benefit is for the retiree only. It is the foundational calculation for all retirees. Most
married retirees will receive the Joint & Survivor Benefit.
3. Less J&S Reduction (if selected): If the retiree is currently married and has been married to the same spouse
for a full year prior to retirement, the Joint & Survivor option is available, and indeed is considered the default
option. However the J&S benefit has a cost. If the retiree and spouse are within five years of each other in age, this
cost will be 10% of the Single Life Benefit. If the age difference is more than five years, the reduction will be
adjusted up or down.
4. Spouse Allowance: This benefit enhances the earned benefit of an employee whose spouse has limited or no
retirement benefit provided from any employer based on the spouse's career. The spouse allowance is reduced by
the amount of any retirement benefits available to the spouse. Only rarely available to hospital employees.
5. Early Retirement Reduction: Normal Retirement Age is based on a sliding scale depending on year of birth. If
the effective retirement date is prior to the Normal Retirement Age, a permanent benefits reduction is calculated
based on how many months the retiree is short of either forty total years of denominational service credit or normal
retirement age, whichever would provide the greatest monthly benefit. Early retirement is not available to hospital
employees.
6. Accrued Pension Supplement: APS is provided to hospital employees in lieu of healthcare assistance. It is
calculated based on years of qualifying service credit. It requires at least 15 years of hospital service credit. Not
available for church employees except in mixed church and hospital service cases where employee has not met
church healthcare eligibility requirements.
7. Medicare B Reimbursement: Retirees who qualify for healthcare based on church service credit are eligible for
a partial reimbursement for the Medicare Part B premium. In order to begin to receive this monthly benefit, the
retiree must send a copy of the Medicare card for retiree and/or Joint & Survivor spouse. If a retiree or Joint &
Survivor spouse is not yet eligible for Medicare at retirement, upon enrollment in Medicare a copy of the card
should be mailed to the retirement office immediately.
8. Supplemental Healthcare, Adventist Retirement Plan is the Plan's healthcare assistance plan. Based on the
options selected by the retiree (if any,) and based on the years of church service credit, including pre -2000 and
post 1999, the cost less the earned credit are offset and the personal monthly contribution is calculated. Except in
unusual mixed service cases, hospital employees are not eligible to participate in S.H.A.R.P.
9. Hospital Lump Sum Payout: This is an estimate of what the Lump Sum Payout in lieu of Pension would be in
today's dollars. This number can change significantly along with interest rates and pension benefits. Effective
1/1/2009, if this amount is $50,000 or less, a Lump Sum Payout is required instead of a pension.
10. One-Time Lump Sum Retirement Allowance: Church employees who go directly from employment into
retirement are eligible for a one-time lump sum benefit based on last pay and years of service credit. The portion
earned prior to 2000 is considered a retirement benefit paid by the Plan. The portion earned after 1999 is
considered an employee benefit.
11. Estimated Survivor Benefits: In the case of death of the retiree, a Joint & Survivor spouse is eligible for survivor
benefits. The J&S Benefit is halved, and any Spouse Allowance is pro -rated based on shared years of service.
12. Estimated Death Benefit: Upon death of a church retiree or J&S Spouse, a death benefit is provided to the
surviving spouse, or a child or estate if there is no surviving spouse.
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