Complete and print this form, sign, and submit to the Pension Trust office.  To begin preliminary processing of your information, hit the "submit" button on the bottom of the page.  Your information will be sent to the trust office, but cannot fully be processed until the office has the paper document with the necessary signatures as well.

NORTHERN CALIFORNIA CONSTRUCTION WORKERS

PENSION TRUST

6834 MISSION STREET, DALY CITY, CA 94030

Telephone: (650) 991-4500

A P P L I C A T I O N  F O R  R E T I R E M E N T

Full Name of Participant

Address

City

State

ZIP

Phone Number

Social Security Number

Date of Birth

Local Union

EXPLANATION OF FORMS OF BENEFITS

Read the following explanation carefully and then complete the entire form.

LIFE ANNUITY:

A Life Annuity is a monthly benefit paid to you for life, with a 3 year certain benefit.  Under the Plan, benefit payments cease after 36 months or at your death, whichever is later. This benefit is the equivalent to the Basic Retirement Income. IF YOU ARE SINGLE, YOU WILL RECEIVE THIS PAYMENT FORM UNLESS YOU ELECT ANOTHER OPTION.

JOINT AND SURVIVOR ANNUITY BENEFIT:

A joint and survivor benefit has two parts: a monthly "joint" benefit paid to you for life, followed by a monthly "survivor" benefit, paid to your spouse for life. Under the Plan, you may elect a survivor benefit equal to 50%,  or 100% of your joint benefit, with benefits adjusted so that the total benefit is actuarially equivalent to the Basic Retirement Income. If your spouse does not survive you, no benefits will be paid after your death. IF YOU ARE MARRIED, YOU WILL AUTOMATICALLY RECEIVE A 50% JOINT AND SURVIVOR ANNUITY UNLESS BOTH YOU AND YOUR SPOUSE ELECT A DIFFERENT OPTION.

POP-UP OPTION

A pop-up option is the same as the Joint & Survivor with the addition that if your spouse dies before you, your benefit will be restored ("pop-up") to a single life annuity for the rest of your life.

This is only available on the 50% Joint & Survivor option.

 STATEMENT OF EMPLOYEE

I hereby request retirement under the Norther California Construction Workers Pension Trust, effective in accordance with the terms of the Plan.  I have read the Explanation of Forms of Benefits and understand the effect of electing the form I have chosen.

Participant Signature                                                               

Date                                     

Address to which Pension Checks will be sent:

Address

City

State

ZIP

Date Last Worked

Employer

Marital Status

Have you ever been divorced?

Date(s) of divorce(s)

If you were previously married during any of the years you participated in this Plan, please attach any court order and marital property settlement from the divorce(s).

Type of Retirement

Form of Benefit

You may elect a pop-up option under the Joint & Survivor Benefit or Contingent Annuitant Option, which provides that if your spouse dies before you, your benefit will be restored ("pop-up") to a Single Life Annuity for the rest of your life.  This option is available on the 50% Joint & Survivor option only.

Include Pop-Up Option

* If you are married, you may not elect any form of benefit other than the 50% Joint & Survivor option  without your spouse's consent.

** If you choose a joint and survivor annuity benefit, complete the section below and provide proof of your spouse's age.

Name of Spouse

Social Security No.

Spouse's Date of Birth

Signature of Spouse                                                                

Date                                       

If you REJECT the Joint and Survivor option.... please complete.

In the event of my death before the expiration of the "certain period" I hereby designate....

Name

Relationship

Social Security Number

Date of Birth

Address

City

State

ZIP

.......as my beneficiary to receive the remaining proceeds.

Signature of Retiree                                         Date

CONSENT OF SPOUSE

I understand that I have the right under federal law to receive a 50% Joint and Survivor Annuity Benefit which will pay benefits to me for my lifetime, and that my spouse may not elect any other form of benefit, or name anyone other than me as his/her beneficiary, unless I give my written consent below.

              I hereby consent to my spouse's election of the following form of benefit:

              I hereby consent to my spouse's designation of the following beneficiary:

I understand that I cannot withdraw my consent to this form of benefit and this beneficiary after my spouse receives the first benefit check from the Plan, and that any withdrawal of my consent must be in writing and delivered to the Plan Administration Office prior to payment of the first benefit check.

Signature of Spouse                               Date             

Signature of Witness                              Date            

IMPORTANT:       This signature MUST be witnessed by a Notary Public.

NOTICE AND ELECTION TO INDIVIDUALS RECEIVING DISTRIBUTIONS

NORTHERN CALIFORNIA CONSTRUCTION WORKERS PENSION TRUST

I.  ELECTION TO WAIVE WITHHOLDING OF TAX

 I elect NO Federal income tax withholding. I understand my responsibilities.

 I elect NO State income tax withholding. I understand my responsibilities.

II. ELECTION FOR WITHHOLDING OF TAX

I request Federal income tax withholding from my gross sum payment.

Dollars Per Month:

I request State income tax withholding from my gross sum payment.

Dollars Per Month:

III. SIGNATURE

Signed by:                                                            Date                   

RETIREE AUTOMATIC ELECTRONIC DEPOSIT AUTHORIZATION

 Automatic electronic depositing puts your pension check amount directly and accurately into your account on the 1st day of each month.  This procedure eliminates postal problems and change of address errors.

If you would like to have your check automatically deposited, please fill in and sign the form below and return to our office along with one of your deposit slips as soon as possible.

I hereby request that my pension checks be electronically deposited to my bank account according to the enclosed deposit slip.

Date

Name

Local Union

Social Security Number

Signature