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Average Compensation for Power of Attorney

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					                                 City of Omaha (Civilian) Employees Retirement System
                                 Request for Refund of Pension Contributions
                                       (Please read and sign acknowledgment on reverse)

                  The Board of Trustees                         Request is hereby made for a refund of Contributions in
   City of Omaha (Civilian) Employees Retirement System         accordance with the provisions of Section 22-39 of the
           Omaha Douglas Civic Center, Suite 506                Omaha Municipal Code for the period of employment shown
                   1819 Farnam Street                           on this form. (Funds will be distributed approximately ten
                    Omaha, NE 68183                             working days after approval by the Board of Trustees.)

Name of Employee (please print)       Department                Social Security Number               Social Security Number
                                                                (of Employee)                        (of Claimant, if Employee is Deceased)



                                                                     Tax/Rollover Option for 414H Refund (applies only to
          Reason for Refund             Term of Employment                   contributions made since 02/11/96)

                                      Starting Date                      Cash Payment. Mandatory 20% withholding for federal tax
                                                                         (& 5% NE tax for Nebraska residents). The federal
                                                                         government may also require a 10% early withdrawal
                                                                         penalty if under age 59 1/2.
                                                                         Rollover to the following qualified retirement account (e.g.,
           Transfer to Sworn                                             traditional IRA).
                                                                (Provide Name on Account, Company, Address, Company Phone #)
           Resignation
                                      Ending Date
           End of Appointment

           Dismissal

           Death




          Mail Information (Must be Completed for 1099)                         Employee/Claimant Signature & Witness


Name
                                                                Employee/Claimant Signature                            Date

Address                                                         I certify that I witnessed the signature of the person making this
                                                                claim.

City                     State              Zip
                                                                Witness Signature
Phone Number
                                                      Do Not Write Below

                                                                Approved for Payment                Yes                   No

                                                                Power of Attorney                   Yes                   No

                                                                Date

                                                                ________________________________________________
                                                                Chair

                                                                ________________________________________________
_________________________________________________               Secretary
Finance Department
                          Date ___________________

                                            Turn Over & Complete Other Side
        REFUND OF PENSION CONTRIBUTIONS/VESTING PENSION CONTRIBUTIONS
Refund --To receive a refund of pension contributions during any given month, the following requirements must
         be met:
          1. Your final pay must have been received by you before the pension Board meeting. The (Civilian)
             Employees Retirement System Board of Trustees usually meets the third Wednesday of each
             month;
          2. The completed refund request form must be received in the Human Resources Department no
             later than noon on the Friday preceding the Board meeting;
          3. Your department must submit a status change (P-19) form to the Records Division of the Human
             Resources Department no later than noon on the Friday preceding the Board meeting.
Vesting --Employees who have received at least five years of service credit under the City of Omaha (Civilian)
          Employees Retirement System are automatically vested unless a refund is made. Vested individuals
          are qualified for a pension, which is based upon years of service and final average monthly
          compensation, upon reaching age 60 (or a reduced pension beginning at age 55). You may, at any
          time prior to starting your pension, withdraw your pension contributions and interest pursuant to
          Omaha Municipal Code 22-38. If you withdraw your contributions and earned interest (refund),
          you forfeit all benefits from the retirement system.

          Former employees who are vested are not entitled to health insurance benefits except as provided
          under COBRA provisions.

          To receive a pension, or for a survivor to receive a pension and/or death benefit upon the death of a
          vested employee, a request must be made to the City of Omaha Benefits Division, Human
          Resources Department, 1819 Farnam Street, Suite 506, Omaha, NE 68183.

          Vested employees are responsible for providing current information to the City of Omaha Benefits
          Division of the Human Resources Department with any change in mailing address or beneficiary(ies).
          (See Designation of Beneficiary form on file.)


             I hereby request a lump sum refund from the pension system and understand that I lose the
             right to any future benefit under the City of Omaha (Civilian) Employees Retirement System by
             this request (refund application on reverse side of this notice).

             I understand that if I should become re-employed by the City of Omaha and re-eligible for
             membership in the City of Omaha (Civilian) Employees Retirement System, I will be considered
             a new member.

             I further understand that upon re-eligibility for membership in the City of Omaha (Civilian)
             Employees Retirement System, I may reclaim prior service credit towards a pension by
             repaying, in a lump sum, the refunded contributions and interest, along with the interest that the
             system earned annually for those years that I was not a member of the system. This lump sum
             must be repaid on or before the end of my probationary period or 6 months, whichever is
             shorter. Such interest shall include the period from re-employment until the repayment is fully
             paid.



                                    Signature                                            Date



                                     Witness




                                       Turn Over & Complete Other Side

				
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