Document GKNnw7Ldp5KnxedrpgN8OgVQY

'wmmum UKIROYAL BB5B&E9 APPLICA*i.jN OF OPTIONAL METHOD OF RETIREMENT i.. .vEFITS POST-RETIREMENT OPTION PLAN A IPS LAST NAME IEI IRI CRISS is: LOCATION NAME 1 FIRST NAME \ M.I. I TRANS. C0DEU-3) 1 SOC. SEC. NO. (4 -12) } JAMES S 1 TET * 11 076 1 1 235-54-6402 * S LOCATION NO.(13 16) s SERVICE DATE |o| |N| Painesville SAI DATE OF BIRTH j 3340 ii DATE OF RETIREMENT 1 1 5-23-71 1 DATE AGE 65 SLl || 5-31-38 1l 1 1 7-01-82 1 1 5-31-2003 I I S_S Statement of employee wishing a Joint and Survivor Annuity at date of retire I I ment. Effective with the later of the date of retirement or my 55th birthday, S I S I understand that my retirement benefit payable to me shall be actuarially re- j os dueed to$ during my lifetime and that after my death to 50$ of my reduced I IPS monthly payment to ay spouse during ay spouse*s lifetime (provided I have been S STS married one year prior to my death), j SIS SOS l_{ Statement of employee wishing a five year certain option. I understand that my I SNS retirement benefit payable to me shall not be reduced during cy lifetime and t s s that my named beneficiary shall receive an allowance for a period of five years S I s commencing with the month following the later of the date of my retirement or S SIS ay 55th birthday and ending on the fifth anniversay of such date. IN! I |F| |t Statement of employee wishing a five year certain option and either a 100$ or t SOS 50$ contingent annuitant option. Effective with the expiration of the five year! Sri certain, I understand that my retirement benefit payable to me shall be actuar- I sms ially reduced to 72.4< during my lifetime to provide a monthly amount payable S SAI equal to 100 $ of my monthly reduced retirement benefit to my named beneficiary I ITS during the beneficiary lifetime, beyond the expiration of five year certain. I SIS SO! IJ Statement of employee wishing a five year certain option and either a 5 10, or I SHI 15 year extended term certain option. Effective with the expiration of the five} S I year certain, I understand that my retirement benefit payable to me shall be } I I actuarially reduced to _____ $ during my lifetime, and in the event of my death I } ! to provide a monthly amount reduced for a period of_____years beyond the ex- { I I piration of the five year certain. ' S XJ_ IBS BENEFICIARY INFORMATION (TO BE COMPLETED IF OPTION IS ELECTED) t IEI I In}. SES F.I. if: us. E. (45)|M.I. s G. (46) :I HAST NAME (47-66) CRISS ISOC. SEC. NO.(30-38) I TYPE OF OPTION (23) S 235-62-4956 } 100% Cont. Annuitajit |C| DATE OF BENEFICIARY BIRTH I DATE OF MARRIAGE,'RELATIONSHIP TO EMPLOYEE lOPTION PERCENT III YEAR MONTH DAY (39-44) |YEAR MONTH DAYS | (24 - 26) IAI 1938 9 IRI 26 jl957 7 11 { spouse j 72.4% 1XL LII II I I I understand the options of the Retirement Plan and the election I have made. 1 I I also understand that if I had elected a Pre-Retirement Joint and Survivor Annuity, I I my retirement allowance would be reduced by 6/10 of 1$ for each year the option was I1stI in eff^t. III lei (J r Cujs&____ Employee Signature Date INI IAS STS 7- /-'fz- IUI Date SRI IEI IS! ..?.///fa IS ir i--L Rev. . Date UNIR0000340