PENSION APPLICATION PENSION TRUST FUND FOR OPERATING ENGINEERS 1640 SOUTH LOOP ROAD by ymt20599

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									                                      PENSION APPLICATION

                         PENSION TRUST FUND FOR OPERATING ENGINEERS
                                     1640 SOUTH LOOP ROAD
                                       ALAMEDA, CA 94502
                         Telephone Numbers: (510) 433-4422 or (800) 251·5014

Instructio ns:

1.   Please read each question carefully.                   5.        THE TRUST FUND OFFICE WILL ACKNOWl·
2.   Print all information.                                           EDGE RECEIPT OF YOUR APPLICATION. NO
3.   Be sure to answer all applicable questions.                      UNION, EMPLOYER OR OTHER OFFICE IS
     This will avoid delay in having your appli·                      AUTHORIZED TO ACCEPT OR RECEIVE THE
     cation processed.                                                APPLICATION ON BEHALF OF THE TRUST
4.   Sign and date the application; mail to the                       FUND.
     Trust Fund office.


PERSONAL DATA

1.      Name                                                                                                         _
                           Last                 First                             Middle

2.      Address                                                                                                      _
                           No. and Street       City                      State   Zip Code

3.      Social Security No.                            _         4. Telephone No.                                        _

5.      Registration No.                                _        6.    Date of Birth
                                                                                             (Attach proof of age)

7.      Date you retired or plan to retire:     Month                                  _     year                        _

8.      Marital Status:            _ _ _ Never Married                    _ _ _ Divorced and Remarried

                 _ _ _ Married      ---Legally Separated _ _ _ Divorced ---Widowed

        Spouse's name (if legally married) - - - - - - - - - - - - - - - - - - - -

        Spouse's Social Security Num ber                                     _    Spouse's Birth date                    _

        Date of Marriage                    .                                                                        _

IMPORTANT! IF YOU HAVE EVER BEEN DIVORCED, YOU MUST SUBMIT A COPY OF YOUR
FINAL JUDGEMENT(S) OF DISSOLUTION OF MARRIAGE ALONG WITH PROPERTY
SETTlEMENT(S) AND QUALIFIED DOMESTIC RELATIONS ORDER(S).


9.      Is this the first time you have submitted a Pension Application to this Trust Fund?                              _
                                                                                                              (yes or no)




        revised 811101


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       TYPE OF PENSION you are applying for:
       (Optional forms of payments will be offered when the amount of benefit has been determined.)

       _ _ _ Normal Pension (age 65 with at least 5 Years of Credited Service; Special Rules apply)
       - - - Regular Pension (age 62 and vested; Special Rules apply)
       - - - Service Pension (rule of 85 or 35/20; Special Rules apply)
       _ _ _ Early Pension (age 55 and vested; Special Rules apply)
       _ _ _ Disability Pension* (vested and 10 years of Credited Service; Special Rules apply)
       - - - Pro-Rata Pension (attains vested status with recjprocal credits; Special Rules apply)

       *Are you receiving Social Security Disability Benefits?       Yes            No
       (If "Yes", attach a photocopy of your award letter from the Social Security Administration. If uNo",
       please explain)



PRIOR EMPLOYMENT HISTORY
List below All employment before your Contribution Date in which you worked as an Operating
Engineer for an employer who later became a Contributing Employer to the Pension Fund, or you
preformed work of the type or kind covered by labor agreements of Operating Engineers Local
Union NO.3 prior to your Contribution Date. This information is important in determining
whether or not you are entitled to Credited SeNiee under the terms of the Pension Plan for any
period prior to your Contribution Date. You may be entitled to Credited Service for work of this
type in the geographic jurisdiction of Operating Engineers Local Union No.3.


                                                                        DATES OF EMPLOYMENT
    NAME OF EMPLOYER                    ADDRESS                    FROM                        TO
                                                               MONTH    YEAR          MONTH           YEAR




EMPLOYMENT HISTORY IN OTHER OPERATING ENGINEERS LOCAL JURISDIGIONS
List below (if any) the names and locations of any other Operating Engineer pension funds in
whose jurisdictions you have worked, and the dates which you worked in each jurisdiction.

                                                                        DATES OF EMPLOYMENT
   NAME OF EMPLOYER                     LOCATION                   FROM                        TO
                                                               MONTH    YEAR          MONTH          YEAR




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UNION MEMBERSHIP

list below your union membership history (if any) in Operating Engineers Local Union NO.3 or
predecessor Locals, or other Operating Engineers Local Unions.


                                             DATES OF MEMBERSHIP
      FROM                            TO                             FROM                        TO
  MONTH    YEAR               MONTH        YEAR   LOCAL          MONTH    YEAR           MONTH        YEAR       LOCAL




MILITARY SERVICE

Military Service that interrupted your employment as an Operating Engineer may count for Credited
Service or help in avoiding a break in service (Special Rules apply). Provide the following data if you
served in the United States Armed Services and attach photocopies of your discharge documents.

Did you serve in the Armed Forces of the United States?                 ___ Yes             ___ No
If "Yes", state:

From                          _       to                         _           Branch                                  _


BENEFICIARY

I hereby designate the following beneficiary to receive any payments under the Pension Plan which
may be due in the event of my death, unless a different beneficiary is subsequently designated. If
you are married and designate a beneficiary other than your spouse, he/she will have to give writ-
ten consent to that designation after the application has been processed and you have been provid-
ed with the Election Package.

Name (in full)                                                           _       Relationship                       _

Address                                                                                                              _
                 NO. and SUe€lt                       City                       State                Zip Code


Social Security No.                               _


I hereby apply for a Pension from the Pension Trust Fund for Operating Engineers. I understand that
my pension application is only valid for one year from the date the application is received in the
Trust Fund Office. I certify under penalty of perjury that all of the above statements are complete,
true and correct, and that this application was signed by me. I understand that a false statement
may disqualify me for pension benefits and that the Board of Trustees shall have a right to recover
any payments made to me because of a false statement.

Date                              _          Signature                                                              _




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                    INSTRUGIONS CONCERNING SUBMISSION OF PROOFS OF AGE

     The acceptable proofs of your age are listed below in two groups. Submit a photocopy of one of the
proofs listed in Group I, if you have it, or can possibly obtain it, since this class of proof of age is the more
convincing.

      If you cannot submit a proof in the Group I classification, submit photocopies of 2 of the proofs list-
ed in Group II. You are cautioned, however, that Naturalization Papers, United States Passports and
Immigration Papers may not be photocopied. If you are
submitting any of these, you must send the original. Jt will be returned to you.

     Additional proofs of age may be requested if the documents you submit do not
constitute convincing proof of your age.


                                                    GROUP I
                                                  (Submit one)

1.     A Birth Certificate.
2.     A Baptismal Certificate or statement as to the date shown by a church record, certified by the cus-
       todian of such record.
3.     Notification of registration of birth in a public registry of vital statistics.
4.     Certification of record of age by the U.S. Census Bureau.
S.     Hospital birth record, certified by the custodian of such record.
6.     A foreign government record.
7.     A signed statement by the Physician or Midwife who was in attendance at birth, as to the date of
       birth shown on their records.
8.     Naturalization record. (Photocopy not permitted; submit original.)
9.     Immigration papers. (Photocopy not permitted; submit original.)


                                                    GROUP"
                                                  (Submit two)

10.    Military record.
11.    Passport. (U.S. Passports may not be photocopied, submit original.)
12.    School Records, certified by the custodian of such record.
13.    Vaccination record, certified by the custodian of such record.
14.    An insurance policy, which shows the age or date of birth.
15.    Marriage records showing date of birth or age (application for marriage license or church record,
       certified by the custodian of such record; or marriage certificate.)
16.    Other evidence such as signed statements from persons who have knowledge of the date of birth.
17.    Letter from Social Security stating your date of birth as shown in their records.




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