Rtd/Atu 1001 Pension Plan

INFORMATION CONCERNING RETIREMENT

Attached is a retirement application for you to complete and forward to the Fund Office.

You will need to forward a copy of your birth certificate with the application and the following if applicable:

1. A copy of your spouse’s birth certificate

2. A copy of your marriage license

3. A copy of your Social Security Disability Award, if applicable

Retirement benefits are usually payable beginning with the first day of the month following your termination from employment with the RTD.

Your monthly benefit amount cannot be calculated until all of your final payroll information has been received in the Fund Office.

Your payments will begin once this process has been completed, which may take several weeks.

PENSION APPLICATION

Instructions:

1.  Please read each question carefully

2.  Please print all information

3.  Be sure to include proper proof of age

4.  Return completed application and proof of age to:

ATU 1001 Pension Plan, 2821 S. Parker Rd, Suite 215, Aurora, CO 80014

1. Social Security Number: ______

2. Name: ______

Last First Middle

3. Address: ______Street City, State Zip

4. Date of Birth: ______5. Sex: ______

Month Day Year

6. Date of Employment: ______7. Phone: ______

8. Transfers, if any, between represented and non-represented employment under the District:

From: ______To: ______Date: ______

From: ______To: ______Date: ______

9. Date of Retirement: ______

10. Name of Beneficiary: ______11. Relationship: ______

12. Beneficiary Soc. Sec. No.:______Date of Birth: ______

RTD/ATU 1001 Pension Plan Page 2

Pension Application

13. Type of Benefit *:

___ Normal Retirement - Later of age 65 or 5th anniversary of date of participation.

___ Regular Retirement - Age 62 with a minimum of five (5) years of credited service.

___ Early Retirement - Minimum age of 50 and 20 years of credited service.

___ Disability Retirement - No minimum age, minimum of five (5) years of credited service and a Social Security Disability Award.

___ Deferred Vested

Retirement - Age 65 with five (5) years of credited service, following a break in employment.

___ Pre-Retirement Death - Payable when the Participant would have been eligible to receive a benefit.

* Please refer to the Summary Plan Description booklet if you have any questions with regard to which type of Pension benefits you will be eligible.

14. Optional Forms of Payment - Please check the appropriate space and provide the requested information. If you are married, you must check one of the forms of payment. If you are not married, you must choose the Single Life Annuity Option.

I do wish to receive my pension benefit in the form of a Single Life Annuity.

I do wish to receive my pension benefit in the form of a 50% Joint & Survivor Pension.

I do wish to receive my pension benefit in the form of a 50% Husband & Wife with Single Life Reversion (Pop-up) Option.

I do wish to receive my pension benefit in the form of a 100% Joint & Survivor Pension.

I do wish to receive my pension benefit in the form of a 100% JOINT & SURVIVOR WITH SINGLE LIFE REVERSION (POP-UP) OPTION.

I do wish to receive my pension benefit in the form of a SOCIAL SECURITY OPTION.

I do wish to receive my pension benefit in the form of a TEN-YEAR CERTAIN OPTION.

RTD/ATU 1001 Pension Plan Page 3

Pension Application

You must check item “A” or “B”. The form must be returned to the Administrative Office before your Pension will begin.

A.____ I do not wish to receive my Pension Benefits in the form of Husband and Wife Pension

B.____ I want my Pension Benefits to be paid as a Husband and Wife Pension.

If “B” is chosen, I want the: ____ 50% Husband and Wife Pension

____ 100% Husband and Wife Pension

Employee’s Name (Print) Employee Signature

Date Social Security No.

SPOUSES STATEMENT

I, , swear that I am the legal spouse of , I hereby consent to my spouse’s election as set forth above:

Spouse’s Signature Date

EMPLOYEE STATEMENT

 I am not legally married at this time

I, , hereby swear, I am unable to locate my spouse (additional proof needed)

 that the person co-signing this document is my current legal spouse.

I certify that the above information concerning my marital status is correct.

Employee’s Name (SIGNATURE) Date

NOTARY CERTIFICATION

On the day of , 20 , before me came

And who personally appeared before me and who are known to

me, a notary public in the state of .

MY COMMISSION EXPIRES:

Notary Public

INSTRUCTIONS CONCERNING SUBMISSIONS OF PROOF OF AGE

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

If you cannot submit a proof in the Group I classification, submit photocopies of two (2) of the proofs listed 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. It will be returned to you.

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

Group I

1.  A birth certificate.

2.  A baptismal certificate or a statement as to the date of birth shown by a church record, certified by the custodian 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.

5.  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 II

1.  Military record.

2.  Passport. (US Passports may not be photocopied; submit original.)

3.  School records, certified by the custodian of such record.

4.  Vaccination record, certified by the custodian of such record.

5.  An insurance policy which shows the date of birth or age.

6.  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.)

7.  Other evidence such as signed statements from persons who have knowledge of the date of birth.

8.  Letter from Social Security stating your date of birth as shown in their records.