Sand Springs Economic Development Authority - SSEDA

FIREFIGHTERS PENSION BOARD NOTICE OF SPECIAL MEETING AND AGENDA November 12, 2013 - 8:30 am Sand Springs Municipal Building 100 East Broadway, Administration Sand Springs, Oklahoma 74063 1. Call to Order 2. Roll Call 3. Minutes The minutes of the July 24, 2014, Special Firefighters Pension Board meeting for the Committee's review and/or approval. ACTION: Application of Death Benefit and Surviving Spouse for Pension Ms. Charlotte F. Lawley, spouse of former Firefighter Tommy R. Lawley, has submitted an Application for Death Benefit and Surviving Spouse for Pension. The Pension Board will consider approval of said application for death benefit and surviving spouse for pension. ACTION: 5. Adjournment This agenda was posted at 8:15 am, on November 6, 2013, on gital display board located in the lobby of the Sand Springs Municipal Building, 100 East y, Sand Springs, Oklahoma, 74063, by Janice L. Almy, City Clerk.  MINUTES Sand Springs Firefighters Pension Board Sand Springs Municipal Building 100 East Broadway - Administration Sand Springs, Oklahoma 74063 July 24, 2013 - 8:15 a.m. The Firefighters Pension Board met in special session on July 24, 2013 in Administration offices of the Sand Springs Municipal Building, pursuant to the special meeting notice and agenda filed with the City Clerk's office and posted at 3:15 p.m., on July 19, 2013 on the bulletin board located in the first floor lobby of the Sand Springs Municipal Building, 100 Easj^roadway, Sand Springs, Oklahoma, 74063. 1. Call to Order The meeting was called to order at 8:: 2. Roll Call It was noted for the records Dan Call, Charlie Bowman, and Janice Almy were in attendan 3. Minutes A motion was nd seconded by Dan Call that the minutes of the Janua efighters Pension Board meeting, as presented, be Ayesj i, Almy Nay: None 4. it and Surviving Spouse for Pension Ms. III, spouse of former Firefighter Rodney G. Broomhall, submitted for Death Benefit and Surviving Spouse Pension. Following review*of the application and discussion, a motion was made by Jeremy Wade and seconded by Charlie Bowman that the requested approval of Application for Death Benefit and Surviving Spouse Pension, as presented, be approved. Ayes: Wade, Call, Bowman, Almy Nay: None 5. Adjournment The meeting adjourned at the noted time of 8:34 a.m. Janice L. Almy, City Clerk  Oklahoma Firefighters Pension and Retirement System 4545 N. Lincoln Blvd., Suite 265 Oklahoma City, Oklahoma 73105-3407 1-800-525-7461 • (405) 522-4600 - Fax (405) 522-4643 www.okfirepen.state.ok.us Application for SurvivingSpouse for Pension Before the Board of Trustees of the Oklahoma Firefighters Pension and Retirement System, Fire Department, City of J if/ \tj(. *'f '^-7,'i f ''' \• '• \.i -^ -. .- - County of i' *-i ^ -'"j1-'' In re; Application for Pension of . pursuant to Oklahoma Statutes, Title II, Section 49-101 and 49-106, Supp. 1981. {member'i name) COMES NOW O t:b\ spouse of ic.n\n\y deceased, and hereby (as shown on social security cardf * makes application to the Board of Trustees of the Oklahoma Firefighters Pension and Retirement System for a pension and respectfully submits the following: 1. That applicant is the spouse of said deceased firefighter, was married to him/her at the time of his/her death for more than thirty (30) continuous months prior thereto. If in line of duty, this does not apply. 2. That at the time of firefighters death said deceased was a parent of the following named unmarried children under the age of eighteen (18) years, or twenty two (22) years of age if the child is enrolled full-time and regularly attending a public or private school or any institution of higher learning, or physically or mentally disabled children, to wit: NAME OF CHILD: BIRTHDATE: NAME OF CHILD: BIRTHDATE: CODE DFPT NAME FOR OFFICE USE ONLY FIREFIGHTERS'S SOCIAL SECURTIY NUMBER . RETIREMENT CODE PREP BY: REV BY: SPOUSt'bBIRIHUAlE > " -•> • ^I«M.O APV BY: MARRIAGEDATE $-& ' & 'i' DEATH DATE / £ ' "AA" O ^NSION AMOUNT DEDUCTIONS (if any): FEDERAL TAX HTHFR [NS. DETAIL DUES STATE TAX rnrniT UNION OTHER A RETIREES DUES Mi<,r OTHER B MUNICIPAL INS. MUTUAL AID OTHER C ENTER DIRECT DEPOSIT INFORMATION BELOW (OR ATTACH A VOIDED CHECK TO FORM) 0 IIL, /,,.'(,->.; //.< / t t ' ^ . y>.-.4.. 7'UjT ^•-/•A^-' /J£X /V^ o BANK NAME BANK ADDRESS ACCOUNT NUMBER BANK PHONE NUMBER ' 'ciTY STATE ZIP CODE ROUTING NUMBER 3. That applicant is the widow of said deceased, who was a fireman duly appointed and enrolled in the Fire Department of C.'>../ i (.' *.j >i *ji \-t_^,_ . Oklahoma at the time of his/her death, and ihat said deceased fireman served a total of ' j i years, _ months, and _ days, as a member of a duly constituted Fire Department of the State of Oklahoma. Thai said service began on the _ _ day of _J_\-. ly , I '>_.''^ , and ended on the day 4a. That said deceased, on the / '. day of •'". •'." / , •-••'' '—•. died from causes not arising in the line of duty or in the course of his employment as a member of said Fire Department. 4b. That said deceased, on the day of , , died by reason of an injury or sickness sustained by him/her while in consequence of the performance of his/her duty as a member of said Fire Department. (over) Form3 Rev 12/08  5a. If Death in Line of Duty, applicant requests that a monthly pension of $_ . be granted. (If regarding a paid firefighter who has served twenty years, applicant is entitled to a monthly pension of one-half (1/2) of the average monthly salary of the firefighter's highest salaried thirty consecutive months of the last sixty months of service. If firefighter served less than twenty years, benefit is based on the average monthly salary of the last thirty months of service.) If regarding a volunteer firefighter, applicant is entitled to the fufl volunteer pension being paid to service retirees.) Said sum to be paid from the Oklahoma Firefighters Pension and Retirement System in accordance with the laws of the State of Oklahoma in such cases made and provided. 5b. If Death was Not In Line of Duty, applicant requests that a monthly pension of $ be granted. (If regarding a paid firefighter, benefit is based on one-half of the firefighter's last sixty months average salary. (If regarding a volunteer firefighter, applicant shall be entitled to 1/20 of the normal volunteer service pension for each year of service.) Said sum to be paid from the Oklahoma Firefighters Pension and Retirement System in accordance with the Jaws of the State of Oklahoma in such cases made and provided. Was firefighter receiving a pension at time of death? Fj<YeS [ No If YES, what was the amount of pension? $ /C" "')''} •>•')' Was firefighter's death a result of injury or sickness sustained by him/her while in or in consequence of performance of his/her duty? | Yes Was firefighter's death a result of injury or sickness from causes not arising in line of duty? |^ Yes | No Did firefighter serve as much as twenty (20) years in one or more fire departments in the state of Oklahoma? |^<Yes j ' No Had firefighter been approved for a vested benefit? If so, what date was benefit to begin? h'> n.,.' f sf ,•"] Dated this day of Applicant's Signature (as shown on social security card) Mailing Address City State ZIP Code State of Oklahoma ) )SS. County of . Phone , first being duly sworn on oath deposed and says that he/she is the Applicant above named that he/she has read the within and foregoing application, knows the contents thereof, and that the statements contained therein are true and correct. Subscribed and sworn to before me ^ I day of My commission expires /^2 I) 7/V ^ -_^ ^ . / / NotaryPublic PLEASE ENCLOSE: 1. MINUTES OF YOUR LOCAL PENSION BOARD MEETING (if applicable) (Minutes from town counsel cannot be accepted). 2. COPY OF DEATH CERTIFICATE 3. COPY OF MARRIAGE LICENSE 4. FEDERAL AND STATE WITHHOLDING TAX FORM (FORM 6)(if not attached, taxes will automatically be withheld due to federal regulations) 5. AFFIDAVIT VERIFYING LAWFUL RESIDENCE IN THE UNITED STATES (FORM 24) 6. A VOIDED CHECK FOR DIRECT DEPOSIT Return to: OKLAHOMA FIREFIGHTERS PENSION AND RETIREMENT SYSTEM 4545 N. Lincoln Blvd., Suite 265 Oklahoma City.OK 73105-3407 Form 3 Rev. 12/08  Oklahoma Firefighters Pension and Retirement System 4545 N. Lincoln Blvd. Suite 265 Oklahoma City, OK 73105-3407 1-800-525-7461 • (405) 522-4600 Fax (405) 522-4643 www.okfirepen.state.ok.us APPLICATION FOR DEATH BENEFIT Title 11, Section 49-113 2 reads in part: Upon the death of an active or retired member, the System shall pay to the surviving spouse of the member if the surviving spouse has been married to the firefighter for thirty (30) continuous months preceding the member's death provided a surviving spouse of a member who died while in, or as a consequence of, the performance of the member's duty for a participating municipality shall not be subject to the marriage limitation for survivor benefits, or if there is no surviving spouse or no surviving spouse meeting the requirements of this section, the System shall pay to the designated recipient or recipients of the member, or if there is no designated recipient or if the designated recipient predeceases the member, to the estate of the member, the sum of Five Thousand Dollars ($5,000). The Death Benefit is subject to state and federal taxation. A surviving spouse may elect to directly rollover the distribution to an Individual Retirement Account (IRA). Only a surviving spouse can make this election. Please indicate your choice below. (CHECK ONE) D Direct Rollover - Please submit a copy of your IRA Agreement {WIDOW ONLY) fm Twenty percent (20%) will be withheld for federal income tax as mandatory under Code section 3405(c) if distribution is paid »• directly to the applicant. (WIDOW ONLY) n If applicant is other than spouse, a Form 19a is required for tax withholding information, (i.e. If benefit is going to a funeral home) _, do hereby make application for the death benefit of who was a member of the Oklahoma Firefighters Pension and Retirement System and served on the .-.".; & ,' u »/..S i'J s-\-i t {/•-'-> Fire Department. The benefit shall be in the amount of $5,000.00 as provided pursuant to Title 11, O.S., Section 49-113.2 and 49-100.1(16) Deceased Member's SSN Applicant's Signature (Widow, Recipient, OR Funeral Home) Applicant's SSN (If applicant is Guardian of minor child, use child's SSN) Mailing Address Tax ID for Estate or Trust (If applicable) City .- State Zip Dated this dav of State of ) Phone )ss. County of ) City Code , first being duly sworn on oath deposed and says that he/she is the Applicant above named, that he/she has read the" within and foregoing application, knows the contents thereof, and that the statements contained therein are true and correct. Subscribed and sworn to before me this _ day of My Commission Expires J L/ / '}/ / Notary Publi If applicant is the Guardian of minor child(ren) or Conservator of mentally or handicapped child(ren), please list names and birthdates Name Birth Date Name Birth Date Form 19 Rev 05/07 (over)  If applicant is the Surviving Spouse of the deceased member, the following items must be submitted with application: Copy of Marriage Certificate Copy of Death Certificate of Member If applicant is Designated Recipient of the deceased member, the following items must be submitted with application: Copy of Death Certificate Separate Tax Form for Designated Recipient (other than spouse) "Notarized Death Benefit Recipient Form must be on file in pension office. If applicant is Administrator of the Estate of the deceased member, the following items must be submitted with application: Copy of Court Order appointing Executor of Estate Copy of Death Certificate of Member ** Death Benefit does not apply to members who have elected a vested benefit. ** Form 13 (Application for Entrance Into the Pension System) must be on file in the State Pension Office in order for an individual to qualify for this benefit Form 19 Rev 05/07