IPF PENSION APPLICATION - ipfweb.org

1 1 Bricklayers & Trowel Trades International PENSION Fund 620 F Street, Suite 700, NW; Washington, DC 20004 Phone: 202/638-1996 Fax: 202/347-7339 1. IMPORTANT DIRECTIONS: YOUR PENSION APPLICATION MUST BE RECEIVED BY THE FUND OFFICE AT LEAST ONE CALENDAR MONTH BEFORE THE DATE YOU WANT YOUR BENEFIT PAYMENTS TO BEGIN. 2. Answering all questions will avoid delays in processing your APPLICATION . 3. Please read all questions carefully and print all answers. 4. You must sign and date the APPLICATION and provide proof of your age and marital status.

2 5. Mail the completed APPLICATION with proof of your age and marital status to the Fund Office at the address listed above. 6. Instructions for providing proof of your age and marital status are found in the attached instructions. 7. An Electronic Deposit Form is attached See Section H. Section A. PERSONAL DATA 1. Name (last) (first) (middle) 2. Address (number and street) (city) (state) (zip code) 3. Phone number ( ) 4. Soc. Sec. Number (area code) 5. Birth date (attach proof) 6. Member # 7.

3 E-mail 8. Last Employer Name 9. Local Union (number/state) 10. Last date of covered employment prior to retirement (month/day/year) 11. Date you wish your benefits to begin (You cannot work during the monthyour PENSION starts.) (month/year) (month/year) 12. Marital Status: (check one and attach proof) I hereby swear that I am Single* (never married) Married Married and Previously Married** Separated* Divorced** Widow(er)** *Notarized in Form of PENSION Payment Section D and D-1 as required **Divorce Decree/Property Settlement Required **If you are married and previously divorced, you must submit a copy of your divorce decree and property settlement agreement for any prior marriage(s) **Death Certificate of Spouse Required IPF PENSION APPLICATION 2 Section B.

4 EMPLOYMENT HISTORY 1. International PENSION Fund Participation Date (month and year Employer contributions were first made on your behalf). Generally this is the same date your Local Union participated in the IPF. 3. Your earliest union initiation or apprentice registration date (for maximum past service) (month/year) (local/state) 4. List below any calendar year(s) prior to your IPF Participation Date in which you worked less than 750 hours in covered employment and give the reason ( military service, disability, employment on referral by local, self-employment).

5 From Month / Year To Month / Year Reason not in covered employment Section C. TYPE OF PENSION If eligible, I want to retire on a (check one): 1. NORMAL PENSION age 64 or older at PENSION start date. (Please indicate last date of employment of any type / / ) month day year 2. EARLY PENSION age 55 through 63 at PENSION start date and not an Inactive Vested Participant. 3. EARLY PENSION While awaiting Social Security Disability Approval I understand that early retirement benefits for months prior to the Social Security Disability PENSION effective date are subject to reimbursement.

6 4. DISABILITY PENSION You must submit a Social Security Disability Award and a physician s statement indicating the nature of your disability and that you are totally and permanently disabled. You should apply if Social Security Disability approval is delayed. (Reduced if commenced before age 64) 2. To be eligible for Past Service Credit, you must have worked in covered employment at least 750 hours per year in two of the three calendar years immediately prior to your IPF Participation Date. List the number of hours you worked in covered employment during the three calendar years prior to the calendar year in which your IPF Participation Date occurred.

7 This information may be available from your Local PENSION or health and welfare fund offices. Year Hours 3 Section D. FORM OF PENSION PAYMENT IMPORTANT Please read Section J Forms of PENSION Payment Information and Section D election Instructions for information regarding options D (1) (2) and (3) and proof of marital status below. If you choose option 1 the remainder of this APPLICATION must be completed in the presence of your spouse and a Notary Public. If you were never married, a Notary Public must witness your signature in Sections D1 below.

8 This APPLICATION cannot be processed unless the following sections are properly completed. Form of Payment Authorizations: (mark only one choice and complete either 1, 2, 3, or 4 below). 1. REGULAR PENSION I do not wish to receive benefits in the signature of applicant form of a Qualified Joint and Survivor PENSION . I am aware that I am electing to receive a lifetime annuity and in the event of my death, regardless of the number of payments I received, no further payment will be made to my beneficiary, as designated in Section E.

9 I understand that rejecting the Qualified Joint and Survivor forms of payment means NO benefits will be paid to my spouse by the Bricklayers & Trowel Trades International PENSION Fund after my death. Spouse and Notary Authorizations: I am the spouse of the above- signature of spouse -referenced applicant. I understand that I have the right to have the Bricklayers and Trowel Trades International PENSION Fund pay my spouse s PENSION benefits in the form of a Qualified Joint and Survivor annuity and I agree to give up that right.

10 I understand that by signing this agreement, I may receive less money than I would have received under the Qualified Joint and Survivor form of payment and I may receive nothing after my spouse dies, depending on the form of payment and beneficiary that my spouse chooses. I consent to my spouse s rejection of the Qualified Joint and Survivor PENSION and agree to my spouse s choice of beneficiary in Section E. I understand that my spouse cannot choose a different beneficiary unless I agree to that change.