Document dQwdqym7v2rzYap95eeEj02jQ

L a rry Thomas CYWI 5-001637 N15277 gr C yAJVAM 1P "^3 PERSONNEL STATUS NOTIFICATION [5 EMPLOYMENT CHANGE IM RATE MAMC Urry TkHt o e t a iu DEPARTMENT / won* LOCATIO* Cfclo|PLPAATiT*fttlW lOCATtOW *f Qc h a n g e in d e p a r t me n t f~l CHANGE IN JOE TITLE KIWIUO. [~] TERMINATION Q OTHEITL. . PROM ............................. -V. JOB TITLE EFFECTIVE OATE iMMtl factary ** II# 1971 > /;-'y RATE date " v- \ mU-. KtOUlITIO V NA-2) REV. 3*70 370 ANfVI0 IT . *gr CYWI 5-001638 FORM W- (tar. Joly IMS) Dteertawat oi tto Tnetuy Employee's Withholding Exemption Certificate ITnytapntealrpilrliweiat ntMn iJuaMnie* tsrry Thowwi s ^/bq south Kenneth Chicago^ Chicago a^^ " l MTnoi ZIFaa** EMPLOYEE: FIN thM ftna with your employ* r. Otherwlas; In mustwtthteidU.3. income Ms from your wegus Hb> OUt SXSaptMo. EMPLOYER: HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS 1. If SINGLE (or if marrisd and wish withholding as singls person), writs "1." If you daim no sumptions, writs "CT. 2. If MARRIED, one sumption sack is allowable for husband and wift If not claimed on anottarosrtiflcstsi. (a) If you daim both of thass exemptions, writs "2"; (b) If you daim on* of (toss sumption* writs "l"; (c) If data neittor of ttsso exemptions, writs "V..................................................... ...................................... 3. Exemptions for ags end blindness (appflcabl* only to you sod your wits but sot to dependents): (a) If you or your wife win bo 65 yean of ags or oidsr at ths end of tbs year, and you data this exsmptioo, writs "1"; If both wig bo 63 or oldar, and you data both of these exemptions, writs "2" ............. OBcaM wtth your rsesiris. If On iTlirni is tolissed0 km eumptisos; District Mractar steMd to advised. (b) if you or your wife an blind, and you data this sxsmpttav writs *1"; if both are blind, sad you data both of mass sumptions. writs "7*..................................................................................................................................... 4. If you data exemptions tor one or more dependents; writ* the number of such exemptions. (Do notdata exemption tors dependent unloss you sis qualified under Instroctios 4 ou other side.)............................................................... 5. If you data additional withholding allowances for tombed deductions HR out and attach Scbadul* k (Form W-4). and ootar the number of allowances daisied (if daimod tils now Form W-4 osch year) ....................................... 6L Add the exemptions and ellowances (if sny) which you have dahned above end enter total........................ T. Additional withholding par pay period under agreement with employer. (See Instruction . .............................R nEETTFT r W wifSSnlrime moptiow gd Ho<rnca< cUjgvd oa UMrtetefU>nUclceeWleS<ewy Mei Mwewe*l>U*weremwr*yrtWeawOOeMW'lI MwilameUUUSi^T (Beta May 2, 1972 IS_ istota CONFIDENTIAL 1n Fo r ma t 'i n REDACTED CYWI 5-001639 1. Number of Exemption*.--Oo net claim more then the correct The death of a spouse or a dependant does not affect your withhold^ number of exemptions. However. If you expect to owe more Income until the next year, but requires the filing of a naw carttflcsta. N poe, tax than wlH be withheld, a smaller number of exemptions may be tibia, fll* a naw caiUflcat* by December J. of th* year In which the claimed or you may enter into an agreement with your employer to death occurs, if you qualify a* a surviving spoua* with dependant child have additional amounts withhold. This Is Important If you have more (children), you may claim your personal exemption on Una last than one employer. If both husband and wife are employed, each may married Individual tor the two years following the year of tha death of ask to have taxes withheld as a ''single" person to avoid owing large your spouse. additional amounts of taxes. Only on* personal exemption may be claimed by nonresident aHern 4. Dependents--To qualify a* your dependant (Una 4 on other aids), a parson (a) must receive mors than one-half of hto or har support other than residents of Canada. Mexico^ or Puerto Rico. from you for the year, and (b) must have leas than $600 gross Income Z Itemized Deductions.--See Schedule A (Form W-4) for Instruction* during tha year (except your child who is a student or who is undar 19 on claiming additional allowance* based on large Itemized deductions. yean of age), and (c) must not b* claimed aa an exemption by sued parson's husband or wife, and (<f) mutt be a citizen or resident of the Z Changes In Exemptions. You may Wo s new cartltlcat* at any time United States or a resident of Canadto Mexico, the Republic of Panama if the number of your exemptions INCREASES. or tha Canal Zone (this doss not apply to an Wan child legally adopted You must ill* a now cartlflcata within 10 days if the number of ax. by and living with a United States- eftbeen abroad),- and M must (1J empttons previously claimed by you DECREASES, for example, because: have your home *e hi* principal residence and be a member of your <a) Your vrlfa (or husband! tor whom you have been claiming exemption household for th* entire year, or (2) be related to you as follows: is divorced or legally separated, or claims har (or hta) own exemption on a separata cartIBcatm (b) The support of a dependent tor whom you claimed exemption is taken over by someone else, so that you ne longer expect to furnish more than half the support tor the year. (e) You find that e dependent tor whom you claimed exemption win r*> calve WOO or mom of Income a# hM own during the year (except your child who Is a student or who Is undar ! years of age>. i CYWI 5-001640 TERMINATION OP EMPLOYMENT Dot* of Report...... NAME OF EMPLOYEE ..... Address of Employe* ....................................................... Dept........................................................... :.......................................................................... Clock No. Occupation ................................... Social S*curity Account No. . 6UC MoEmploye* recommended for re-employment?.... .............. Other remarks: STUM* FMM IIS HOST STMOMS FOMS. INC. fm*. 30. M. Authorized by jCloZlSri THIS IS A CONFIOWTUU IPOtr AND MUST IS PlACfD IN HANDS OP HOW DVAATMiNT MAD IMMCDIATBY CONFIDENTIAL INFORMATION REDACTED CYWI 5-001641 November 5, 1973 Insurance Company of North America 10 S. Riverside Plaza Chicago, Illinois 60607 Attention: Mr. Robert Ward Dear Mr. Ward: The attached trial schedule, received by us today, relates to a case you are handling for us under file number 911 C 828371. I understand that no further action Is required of us concerning this case. Very truly yours. RKF:ak R. K. Falter Plant Manager 1 CYWI 5-001642 r r-; *i >V '*\-.' -V V--W? -i - .:*) f. . '*r' < . *. / 4a FINAL n o t ic e Respondent) The above case is^fo^131 IN S^SON OF ILLINOIS Secretary i*s# { -}r ,i i . t i-.'yTi.X ; --r v /t|'vt.T * }-*. g i '-V- v T, . . </.- ? :i ^ i! 'f^-v i;.v v ' ''.f***. &'*' ^ i &*>mfw^vwv -i av. CYW1 5-001643 Pwj. Qjip C\ ** INA INSURANCE COMPANY OF ILLINOIS INSURANCE COMPANY OF NORTH AMERICA Life Insurance Company of North America - Pacific Employers Group - 10 South Riverside Plaza, Chicago. Illinois 60606 May 3, 1973 Telephone (312) 454-4000 America Cyanamide Company 4500 West 15th Street Chicago, Illinois 60623 Attn: R. K. Felter, Plant Manager Re: File No. 911 C 828371 . Insured: America Cyanamide Co. Claimant: Larry Thomas Date of Event: 5/25/72 Gentlemen: We wish to acknowledge the Notice of Filing of Claim before the Illinois Industrial Commission, No. 73 WC 1088, entitled, Larry Thomas, Petitioner, vs. McGregor Lead Company, Re spondent. We have referred this matter to Attorney, Patrick J. Reynolds, 179 West Washington Street, Chicago, Illinois 60601, who will take the necessary steps to protect your company's interests in this matter. It will not be necessary for your company to do anything further unless contacted by the above mentioned law firm, or an authorized representative of the Insurance Company of North America. Very truly yours, PAB :dj < CVA iVA MI> August 21, 1973 Insurance Company of North America 10 South Riverside Plaza Chicago, Illinois 60607 ATTNt Mr. Robert Ward Dear Mr. Wards The attached Is related to an active claim you are handling for us. The Incident carried file number 911 C 828371 while the claim Itself Is number 73 WC 1088. Please let me know If you need anything further from us. Very truly yours. R. K. Fetter Plant Manager RKFtfw 1 CYWI 5-001645 Br u c e S. Benny RtcMAno S. Gone Ken n et h a. Gone Be r r y a n d Go r e , Lt d . ATTORNEYS AT LAW ' XSt NORTH LASALLE STREET SUITE XXSO CHICAGO. ILLINOIS SOSOI Tel eph o n e (312) 44>8S80 August 15, 1973 McGregor Lead Company 4500 West 15th Street Chicago, Illinois ATTENTION: Claims .* 4 * Re: Thomas vs. McGregor Lead Gentlemen: Enclosed is the medical report on the above case. Please contact me regarding settlement of this case. Very truly yours, BERRY & GORE Uc/' RSG/chj enc. Richard S. Gore i CYWI 5-001646 Berry and Gore Attorney* et Lev 221 It. Le 8*11* St Chicago, TL. 60601 April 27, 1973 .' > i >- ' l ,4vl ^ Ha 7B0HA*. Urry d a is or mnncrt o/a nay e, 1972 DAZE or EXAHXHATX08: April 21, 1973 PAST HISTCKTi ^22^6'$$^ 186 pound* in *eight( d'miasaiif^ right handed) ho previoai thiury to involved part. -) ' ar\: *- 4."- OVtaS- Very truly 7*^*1 > j ^ ruicr 9* 4 s c c.? t 'OuJU;--;v 4. ?--nac <- DAVID 918881, M.D. . i (oof i *-;.<V w ' > p- ;'ovo<^ V. * i - vi'4^,1' . g. >* Vr. - c o n f id e n t ia l w e s 5SS S-% * y ->>+ r V ' C * * - ? CYWI 5-001647