1000 burnett avenue, suite 110 concord, ca 94520-2000 · pdf file1000 burnett avenue, suite...

1000 Burnett Avenue, Suite 110 • Concord, CA 94520-2000

Mail: P. O. Box 4102 • Concord, CA 94524-4102

Telephone: (925) 746-7530 • (800) 552-2400 • Facsimile: (925) 746-7552

www.ufcwtrust.com

RE: Retirement Application and Checklist

Enclosed are instructions for completing your application for retirement benefits. The enclosed

checklist is provided to make it easier for you to know what is required to process your application.

• Complete both sides of the enclosed Retirement Application in its entirety.

• Return all applicable documentation with your Retirement Application. The date your

application is received in our office may affect your eligibility for retroactive benefits.

Therefore, we recommend that you file your application even though you may need

additional time to obtain some of the required documentation.

• Keep a photocopy of your Retirement Application and documents for your records.

• In addition to the application, the following disclosures, which require no action on your

part, have been included. Please ensure you read each of the following carefully:

o Explanation of Payment Options

o Relative Value Disclosures

o Notice of Right to Defer Commencement of Benefits

o Annual Notice of Re-Employment Restrictions

o Termination of Employment and Eligibility for Retirement Benefits Notice

Complete and return all necessary forms to avoid your benefit from being delayed. We will

contact you if any additional information is required.

Should you have any questions, please contact the Trust Fund Office at (800) 552-2400.

Sincerely,

Pension Department

http://www.ufcwtrust.com/

1000 Burnett Avenue, Suite 110 • Concord, CA 94520-2000 Mail: P. O. Box 4102 • Concord, CA 94524-4102

Telephone: (925) 746-7530 • (800) 552-2400 • Facsimile: (925) 746-7552 www.ufcwtrust.com

APPLICATION CHECKLIST – JOINT PENSION PLAN SIGN AND RETURN THIS CHECKLIST WITH YOUR APPLICATION

(INCLUDE ALL ITEMS STAPLED TOGETHER)

RETIREMENT APPLICATION – (FRONT PAGE OF APPLICATION)

Complete all personal information on the application

Choose your type (s) of retirement

Have your signature notarized. Sign your application in front of a Notary, Union Local or Fund Office

Representative. The date of your signature must match the date of the notarization.

RETIREMENT APPLICATION – (BACK OF APPLICATION)

Complete your Employment History in its entirety including industry time and all other periods of

employment through the current date. Include union or non-union employment, exempt employment,

injuries and/or disabilities, periods of unemployment and any UFCW employment outside of Northern

California.

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

If you wish to share Personal Health Information with the Pension fund, complete all applicable sections

and the sign release form.

DOCUMENTS – PLEASE PROVIDE LEGIBLE COPIES OF ALL APPLICABLE DOCUMENTS

Birth Certificate Spouse Birth Certificate Certified Marriage Certificate (Nevada Marriage Certificates require book and page number)

Copy of Military Discharge papers (DD-214) Divorce Judgments

Certified Death Certificate (if filing for Surviving Spouse Benefits)

POTENTIAL DISABILITY CREDIT

I was off work due to a disability that began on or after March 1, 1992 and received State Disability or

Workers Compensation benefits. (Please submit copies of your benefit payment statements. You may be

entitled to additional Benefit Credit. If you do not have all copies, please contact State Disability for form

DIS0306 or Workers Compensation to obtain a printout of their payment records for your entire period of

disability).

I did not receive any State Disability or Workers Compensation benefits.

Signature: Date: SSN:


The following is a list of acceptable proof of age documents.

(A) The best evidence, if you have or can obtain it, is:

1) A birth certificate, or

2) A hospital record established during the first few years of life and certified by

the custodian of the record, or

3) A religious record of birth which shows the date of birth and was established during the first few

years of life, or

4) A document showing approval of a Social Security Pension and date of birth.

You may obtain a certified birth certificate by requesting a copy from the court recorder in the county in which you

were born. If you do not have one of these records in your possession, try to obtain one. If there was a church

record of your date of birth made when you were an infant or a child, it is probably still on file at the church.

Social Security has a complete list of addresses and fees for public birth records in the United States and in many

foreign countries. You may want to call Social Security to find out where to write and how much to send to obtain

your birth record. Their number is 1-800-772-1213.

(B) If you cannot obtain one of the documents listed under (A), you must state in writing that a certification of

the registration of your birth is not available before we can accept two (2) of the items listed under (B).

Additional evidence of age may be requested if the documents which you submit are not sufficient.

1) A school record

2) A religious record showing date of birth or age

3) A state or federal census record (established near the date of your birth)4) A statement signed by the physician or midwife who was in attendance at the birth as to the date of

birth shown on their records

5) A Bible or other family record (do not remove the page; we must examine the publication)

6) An insurance policy which shows age or date of birth

7) A marriage record showing age or date of birth8) A passport

9) An employment record showing age or date of birth

10) A military record

11) A delayed birth certificate

12) A child’s birth certificate which shows age of the parent

RECORDS WHICH MIGHT BE AVAILABLE TO THOSE BORN IN FOREIGN

COUNTRIES ARE THOSE LISTED ABOVE, PLUS THE FOLLOWING:

1) A foreign passport

2) An immigration record established upon arrival in the United States (Social Security can provide

information and an application form which will help you in obtaining this record)

3) A naturalization record (citizenship papers)

4) An alien registration card

INSTRUCTIONS FOR COMPLETING AN APPLICATION

FOR RETIREMENT BENEFITS

• Complete both sides of the application in its entirety.

• File the application immediately with the Fund Office even though you may need further timeto obtain some of the required documents. Forward the necessary documents to the FundOffice as soon as possible. The date the application is received may affect your eligibility forretroactive benefits.

• Keep a photocopy of your application and documents for your records.

Your application cannot be completed without the following documents:

• Proof of Date of Birth of Applicant (required of all applicants). Please list all names in the box“ALL OTHER NAMES” including maiden name and all previous married names, if applicable.

• Certified Copy of Marriage License and Proof of Date of Birth of Spouse, if married. Please list allnames used by your spouse in the box “SPOUSE’S PRIOR NAMES” including maiden name orprevious married names, if applicable.

• If you are filing for Surviving Spouse benefits as the legal surviving spouse of a vested memberor retiree, please provide a certified copy of the member’s death certificate. Please completethe retirement application as the “Applicant” for benefits and provide all available informationregarding the member’s Industry Employment. If the member was not retired, please alsosubmit a certified copy of your marriage license and proof of the member’s date of birth.

• If you were previously divorced, please provide a copy of your divorce documentation such asfinal judgments or divorce decrees (filed with the court and signed by the judge), qualifieddomestic relations orders (QDRO), marital settlement/property agreements, etc.

YOUR INITIAL RETIREMENT AWARD CHECKS, ONCE ISSUED, WILL BE FORWARDED TO YOUR UNION LOCAL OFFICE. THEREAFTER, THEY WILL BE MAILED TO YOUR DESIGNATED MAILING ADDRESS.

UFCW & EMPLOYERS TRUST, LLC


Telephone: (925) 746-7530 • (800) 552-2400 • Facsimile:

(925) 746-7552 WWW.UFCWTRUST.COM

RETIREMENT APPLICATIONUFCW-Northern California Employers Joint Pension Plan

APPLICANT'S NAME SEX

Male

Female

SOC. SEC. NUMBER

STREET ADDRESS DATE OF BIRTH

CITY STATE ZIP E-MAIL ADDRESS

AREA CODE & TELEPHONE NUMBER ALL OTHER NAMES (including maiden name)

DATE OF RETIREMENT

01 MONTH DAY YEAR

LAST DAY ACTUALLY WORKED

MONTH DAY YEAR

SPOUSE'S NAME MEMBER'S LAST EMPLOYER

SPOUSE'S DATE OF BIRTH DATE OF MARRIAGE HAS THE MEMBER EVER WORKED IN THE INDUSTRY OUTSIDE

NORTHERN CALIFORNIA? Yes No

If yes,

provide location CITY STATE

DATES From To

SPOUSE'S SOC. SEC. NO. SPOUSE'S PRIOR NAMES (incl. maiden name)

WERE YOU EVER DIVORCED? Yes No

IF YES, PROVIDE DATE DIVORCE FINAL

IF YOU WERE A UFCW UNION MEMBER, PLEASE LIST YOUR LOCAL

I HEREBY APPLY FOR THE BENEFITS AS CHECKED BELOW, FOR A DESCRIPTION OF THE ELIGIBILITY RULES FOR EACH TYPE

OF BENEFIT, PLEASE REFER TO YOUR SUMMARY PLAN DESCRIPTION BOOKLET.

Normal - Normal Retirement Age with Vested rights.

Early - Early Retirement Age with Vested rights.

Rule of 85 - Under Normal Retirement Age with Vested Rights and sum of age and Benefit Credits total 85 or

more. (Available under the UFCW-Northern California Employers Joint Pension Plan only).

Survivor Benefits on behalf of deceased member - provides survivor benefits to eligible surviving spouse or dependent child of

a deceased member who had attained Vested rights and had met other requirements under the applicable Plan

Alternate Payee - provides benefits to a former spouse with a Qualified Domestic Relations Order (QDRO) on file with the Trust

Fund Office.

THIS DOCUMENT MUST BE SIGNED BY YOU AND A NOTARY PUBLIC OR AN AUTHORIZED UFCW NORTHERN UNION OFFICAL

OR AN AUTHORIZED TRUST FUND OFFICE REPRESENTATIVE.

I hereby certify that the information provided on this form is true and correct.

[ I ] APPLICANT DATE SIGNATURE

[ II ] State of California, County of

Subscribed and sworn to (or affirmed) before me on this day of

, 20 , by , proved to me on the

basis of satisfactory evidence to be the person(s) who appeared before me.

Signature

NOTARY SEAL, OFFICE SEAL OR UNION STAMP

- OR -

[ III ] UNION/FUND OFFICE

REPRESENTATIVE SIGNATURE DATE

APPLICANT IDENTIFICATION:

(Driver’s License, Passport,

State Issued Personal ID) ID # EXPIRATION DATE

ISSUER

PLEASE COMPLETE REVERSE SIDE


EMPLOYMENT HISTORY IN INDUSTRY

NAME OF STORE/COMPANY CITY

CLASSIFICATION (CLERK,

(MEATCUTTER, PHARMA-

CIST, MANAGER, ETC.)

DATES OF EMPLOYMENT HOURS

SCHED. WEEKLY

FROM TO

MONTH YEAR MONTH YEAR

PRESENT OR LAST EMPLOYER

1. Present

2.

3.

4.

5.

6.

7.

8.

Complete the section below for ALL periods

of your work history during which you were not in a union position in the industry:

REASON FROM TO

MONTH YEAR MONTH YEAR

Military Service (Attach Form DD-214s)

Illness or Injury (Supply doctor's name and address below) if disability began 3-1-92 or later, and you were absent

from food or meat industry employment, submit copies of State Disability or Workers Compensation benefits.

Exempt Employment in CA

(EMPLOYER/POSITION/LOCATION)

UFCW employment outside No. CA

(EMPLOYER AND LOCATION)

dustryWorked in other industry or trade

(EMPLOYER AND TYPE OF WORK)

Self-Employment

(TYPE OF STORE/INDUSTRY/LOCATION)

Other Reasons

(State briefly

and give dates)

If you are not retiring directly from employment, indicate your work status from your last date of employment to the present:

Please list the name of your employers, addresses, positions held and dates of employment.

JP Retirement Application 07_2013 LC

1000 Burnett Avenue, Suite 110 • Concord, CA 94520-2000


Telephone: (925) 746-7530 • (800) 552-2400 • Facsimile: (925) 746-7552

www.ufcwtrust.com

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

By signing below, I authorize the UFCW & Employers Trust, LLC (the “LLC”) to disclose the personal

health information of the person named in Section 1, as described in this Authorization.

I understand that the LLC will not condition treatment, payment, enrollment or eligibility for health plan

benefits on whether or not I sign this Authorization.

I understand that I am entitled to receive a copy of this Authorization.

PLEASE PRINT

1. Name and Member Identification number of person whose health information may be

disclosed:

Name: Member ID:

2. Name of the organization you wish to receive and use the health information.

UFCW & Employers Trust, LLC Pension Staff

Other:

(Name of person or organization to receive and use health information)

I understand that after the designated person or organization receives and uses the health information,

federal law might not protect the information, and the person or organization that received and used the

health information might disclose it again. However, I have the right to seek assurances from the person

or organization identified above that it will not re-disclose the health information to any other party

without my express, additional authorization to do so.

I understand that the UFCW-Employers Benefit Plans of Northern California Group Administration LLC

Pension Staff will not re-disclose the information they receive from LLC or the Fund under this

authorization without my written permission.

3. Please describe the information you wish the LLC or the Fund to disclose, or you may

choose one or more of the examples listed:

Information related to eligibility, claims or payments for benefits that are necessary to process my

pension application.

Other information (describe and include relevant dates, and attach relevant

documents):_


Check here if documents are attached

4. Please describe why you wish the LLC or the Fund to disclose the information, or choose

one or more of the reasons listed. If you do not wish to state a specific purpose, check “At

my request.”

At my request

To determine my eligibility for an excused absence or other disability-related benefits

To discuss my benefits with Fund Office staff

Other:

5. You must limit the time period during which this Authorization is effective. You may

choose one of the following expiration dates, or state another expiration date:

Upon receipt of Pension Benefits

One year from the date of my signature below

When the following event happens:

On the following date:

I understand that this Authorization is voluntary, and that I may revoke it at any time by sending a

written request to revoke to the LLC and/or the Fund at the address above.

I understand that the revocation will only be effective after the LLC or the Fund receives and logs my

revocation, and any use or disclosure made under this Authorization before the revocation is logged will

not be affected by the revocation.

Signature of Person or Personal Representative

Signature of Person Date Signed

OR

Signature of Person’s Personal Representative Date Signed

The personal representative signing this Authorization warrants that he or she has the authority to do so

on the following basis:

Power of Attorney for Health Care (attach document)

Appointment of Personal Representative Form filed with the Trust Fund Office

Other (describe and attach documents):

(e.g., Appointment of Conservator or Guardian) Pension Auth to Release Medical Info 02_2013

- 2 -

The following pages are disclosures which require

no action on your part. Please keep them for your

records and read them carefully:

1) Explanation of Payment Options

2) Relative Value Disclosures

3) Notice of Right to Defer Commencement of Benefits

4) Annual Notice of Re‐Employment Restrictions

5) Termination of Employment and Eligibility for Retirement

Benefits Notice

UFCW – NORTHERN CALIFORNIA EMPLOYERS JOINT PENSION PLAN

P.O. BOX 4102 CONCORD, CA 94524‐4120 TELEPHONE: (925) 746‐7530 (800) 552‐2400

19569026v.1

EXPLANATION OF PAYMENT OPTIONS

April 2015

Below is an explanation of the payment options available to you. Please refer to the Summary Plan Description and the Important Notice of Changes in Your Benefits document dated October 2011 for more information. Please note that your benefits may be different if you had prior service under the former California Butchers’ Pension Trust Fund and incurred a Separation from Covered Employment prior to that Fund’s merger into the Joint Plan in 1998 or if you had prior service under the Retail Clerks Unions Employers Benefit Plans of Northern California and incurred a Separation in Service prior to 1976.

A. Regular Form of Benefit

The Plan’s Regular Form of Benefit is a 50% Joint and Survivor Annuity for participants who are married at retirement and a Straight Life Annuity for participants who are not married at retirement. For purposes of this Plan, your spouse is the individual who is legally married to you, as recognized under the laws of the state or jurisdiction in which the marriage was entered.

If you are married at retirement, your retirement benefits will be paid in the form of a 50% Joint and Survivor Annuity, unless you elect, and your spouse consents to, another Form of Benefit. The 50% Joint and Survivor Annuity is actuarially adjusted to take into account your age and your spouse’s age on your retirement date and provides a reduced monthly benefit payable for your lifetime. If you die before your Surviving Spouse, 50% of your monthly pension benefit (referred to as the “Surviving Spouse Benefit” or the “Spouse’s Benefit”) will be paid to your Surviving Spouse for his or her lifetime. If your spouse dies before you, your monthly pension will not increase but will continue to be paid until your death. Please note that in order to be eligible for a Surviving Spouse Benefit your surviving spouse must have been legally married to you on your retirement date and for at least the 12 months immediately preceding your death (with exceptions made as required by law for eligible ex‐spouses or alternate payees). You may contact the Trust Fund Office for more information regarding the adjustment factors used in calculating the 50% Joint and Survivor Annuity.

If you are unmarried at retirement, your retirement benefits will be paid in the form of a Straight Life Annuity. A Straight Life Annuity (also referred to as a Single Life Annuity) is paid to you for as long as you live and it stops upon your death. No survivor benefits are payable under the Straight Life Annuity.

19569026v.1

Example #1. If you retire at age 65 (with a 65 year old spouse) and qualify for a Normal Retirement Benefit in the amount of $1,000.00 per month and you choose the 50% Joint and Survivor Annuity, your retirement benefit will be reduced to $902.00 per month (adjusted by 90.2% based on both of you being age 65 ‐ different factors apply to different participant and spouse ages to support a 50% Surviving Spouse Benefit for your spouse at retirement). After your death, your Surviving Spouse will receive a monthly benefit of $451.00 per month for the rest of his or her life (50% of $902.00 = $451.00).

Example #2. If you are unmarried on your retirement date, you will not have the choice of a 50% Joint and Survivor benefit, but instead will receive a Straight Life Annuity in the amount of $1,000.00 per month. This monthly payment will stop on your death and no survivor benefit will be payable at your death.

B. 75% Joint and Survivor Annuity Option for Married Participants

Like the 50% Joint and Survivor Annuity form of benefit, the 75% Joint and Survivor Annuity makes it possible for you to assure that your spouse (if he or she survives you) will continue to receive benefits after your death.

The 75% Joint and Survivor Annuity, which is available for retirement dates on and after January 1, 2009, provides a reduced monthly benefit during your lifetime. If you die before your Surviving Spouse, 75% of your monthly benefit will be paid to your Surviving Spouse for his or her lifetime. If your Spouse dies before you, your monthly pension benefit will not increase but will continue to be paid until your death. Like the 50% Joint and Survivor Annuity described above, to be eligible for a Surviving Spouse Benefit, your surviving spouse must have been legally married to you on your retirement date and for at least the 12 month period immediately preceding your death. You may contact the Trust Fund Office for more information regarding the adjustment factors used in calculating the 75% Joint and Survivor Annuity Benefit.

Example #3 Using the facts from the earlier example, if you retire at age 65 (with a 65 year old spouse) and qualify for a Normal Retirement Benefit in the amount of $1,000.00 per month, and you choose the 75% Joint and Survivor Annuity Option, your benefit will be reduced to $860.00 per month and after your death your surviving spouse would receive a monthly benefit of $645.00 per month for the rest of his or her life (75% of $860.00 = $645.00).

19569026v.1

C. Straight Life Annuity Option for Married Participants

The Straight Life Annuity Option is available to married participants who wish to waive their right to receive either a 50% or 75% Joint and Survivor Annuity. If you elect to receive your benefit as a Straight Life Annuity, no reduction would be made to your benefit (other than any reduction for early retirement, if applicable), and no survivor benefits will be payable at your death. However, before the Plan can accept your waiver of a Joint and Survivor Annuity in favor of an election of the Straight Life Annuity, the Trust Fund Office must receive your spouse’s properly witnessed written consent.

Example #4. Using the same facts in the prior examples, if you choose a Straight Life Annuity instead of the 50% Joint and Survivor Annuity and your spouse consents, your Normal Retirement Benefit would be $1,000.00 per month for your lifetime with no survivor benefit payable at your death.

Summary of Rules for the Payment of a 50% or 75% Joint and Survivor Annuity

1. The 50% or 75% Joint and Survivor Annuity protects only a spouse who islegally married to you on the date your pension begins (or a former spousepursuant to a Qualified Domestic Relations Order) and who is still alive atyour death.

2. Your spouse is the individual who is legally married to you, as recognizedunder the laws of the state or jurisdiction in which the marriage wasentered.

3. Your spouse must have been legally married to you for at least the 12month period immediately preceding your death in order to receive aSurviving Spouse Benefit.

4. If your spouse dies before you, the amount of your monthly pensionbenefit will not be increased, and all pension benefits will stop at yourdeath. If you subsequently remarry, your new spouse will not be entitledto a Surviving Spouse Benefit.

5. A written rejection or revocation of the 50% Joint and Survivor Annuity(including any changes made to a prior choice) must be accompanied bythe properly witnessed consent of your spouse and must be received bythe Trust Fund Office before payments can begin.

6. Once payments have begun, the monthly benefits must continue underthe same payment form, even if your marriage is dissolved.

19569026v.1

D. Timing of Pension [For more information, please refer to “When Your Benefits Begin” in the Summary Plan Description on page 12]

If you are younger than Normal Retirement Age (as defined by the Plan), the Pension Plan provides that your pension benefit cannot begin before you are provided with this explanation of the benefit options available under the Plan, as well as the Relative Values Disclosure document. These documents, along with the Plan’s Notice of Right to Defer Commencement of Benefits document, are intended to provide you with sufficient information so that you can make informed decisions when retiring. This also means that your benefits will become effective no earlier than the first day of the first calendar month following the date your completed pension application is received by the Trust Fund Office.

Additionally, the law requires that if you are younger than Normal Retirement Age, you must terminate your employment before you can begin to receive pension benefits from the Plan. This is referred to as the “termination of employment” rule. Benefits cannot start unless you have the present intent to retire, which requires terminating any and all employment with all Contributing Employers to the Plan. Therefore, in order to retire before Normal Retirement Age, you cannot be employed by a Contributing Employer in any capacity, whether or not the employment is covered by a collective bargaining agreement.

IMPORTANT NOTE FOR PARTICIPANTS UNDER NORMAL RETIREMENT AGE: If you are younger than Normal Retirement Age you will not be eligible to begin receiving retirement benefits if you work any hours for any Contributing Employer in any capacity in the month in which your retirement benefits would otherwise become effective. You will not receive any benefit payments and you will be required to file a new application for retirement benefits once you have met all eligibility requirements in order to receive your retirement benefits. Please note that this “termination of employment” rule does not replace the Plan’s Suspendible Service rules (see below). The Suspendible Service rules must be adhered to as well.

IMPORTANT NOTE FOR PARTICIPANTS OVER NORMAL RETIREMENT AGE: If you are older than Normal Retirement Age, this Plan allows you to elect a Retroactive Annuity Starting Date (RASD) back to the date you attained Normal Retirement Age, subject to the Suspendible Service rules (below). A RASD is a date you elect that occurs prior to your having received your Explanation of Payment Options. If you elect to commence benefits retroactively, you will receive a lower monthly amount than you would receive as of the prospective Annuity Starting Date. You will receive interest on the monthly payments from the retroactive date up to the date of payment.

19569026v.1

E. Suspendible Service Rules [For more information, please refer to “Returning to Work” in the Summary Plan Description starting at page 29]

Whether you retire before or after Normal Retirement Age, the Plan restricts the number of hours you can work for certain employers, whether or not they contribute to the Plan. These restrictions apply to employment in the same industry, in the same trade or craft, and in the same geographic area covered by the Plan while you are receiving pension benefits. Under the Plan, such work is defined as “Suspendible Service”.

If you work in Suspendible Service, your pension payment will be suspended for each month you work in excess of 63 hours per month. Your benefit payments will resume when you are no longer employed more than 63 hours per month. There is an exception for work in vacation relief (up to 756 hours in a calendar year), provided you notify the Trust Fund Office in writing in advance of the date you begin such employment. Please see your Summary Plan Description or contact the Trust Fund Office for more information.

Once you reach age 70, your retirement benefits will not be suspended, no matter how many hours you work. If your benefits are suspended before you reach age 70, they will no longer be suspended beginning the first day of the month after the month in which you reach age 70.

F. 30‐Day Notice Requirement and Waiver

In addition to the above requirements, the law states that your pension benefit cannot begin until at least 30 days after your receipt of this Explanation of Payment Options document, unless you waive your right to have at least 30 days to decide which form of payment you would like to receive. Therefore, if you want your pension benefit to begin on the first day of the month following the date that you submit your completed pension application, and at least 30 days has not elapsed since you received this document, you must complete the Participant’s Wavier of 30‐Day Notice form and submit it to the Trust Fund Office before payments begin. In no event will payment be made before the 8th day after you are given the Explanation of Payment Options document.

If you do not complete and return the Participant’s Waiver of 30‐Day Notice form, your first pension payment can begin no earlier than the first day of the calendar month that follows the later of: (1) the date you submitted your completed pension application to the Trust Fund Office, or (2) the date that is at least 30 days after you received this Explanation of Payment Options document.

1000 Burnett Avenue, Suite 110 · Concord, CA 94520-2000

Mail: P. O. Box 4102 · Concord, CA 94524-4102

Telephone: (925) 746-7530 · (800) 552-2400 · Facsimile: (925) 746-7552

www.ufcwtrust.com

NOTICE REGARDING WAIVER OF THE 30-DAY PERIOD

The UFCW- NORTHERN CALIFORNIA EMPLOYERS JOINT PENSION PLAN provides that all Participants who are married will have their benefit payable in the form of a Joint and Survivor Annuity provided that on the date of death they had been married throughout the preceding year. The Joint and Survivor Annuity provides that upon the death of the Participant a payment shall be continued for the life of the surviving spouse.

You may, however, reject the Joint and Survivor form of annuity and have your annuity payable only for

your lifetime. If you reject the Joint and Survivor annuity you and your spouse must complete the

attached Waiver of Joint and Survivor Annuity.

If the Waiver of Joint and Survivor Annuity is completed, your benefit payment will be issued no

sooner than 30 days unless you and your spouse also complete the attached Waiver of the 30-Day

Notice Period.

When selecting your Retirement choice, if you do not elect the Joint and Survivor benefit please also

complete the Waiver of Joint and Survivor Annuity and Waiver of the 30-Day Notice Period.





www.ufcwtrust.com

WAIVER OF THE 30-DAY NOTICE PERIOD

The UFCW – NORTHERN CALIFORNIA EMPLOYERS JOINT PENSION PLAN Board of Trustees is required to

provide you with a written explanation of the effect of your available pension payment options, as

described in the Plan document and Summary Plan Description. This written explanation must be

provided to you no earlier than 180 days and no later than 30 days before your payments begin.

However, your benefit payments may become effective before the end of the 30-day period if you and

your spouse waive this 30-day requirement, in writing.

Please note that under no circumstance may your benefit payments commence before the 8th day after you are provided with the written explanation.

THE PARTICIPANT (AND SPOUSE) SIGNATURE(S) BELOW MUST BE WITNESSED BY A NOTARY, PLAN REPRESENTATIVE, OR UNION LOCAL OFFICIAL.

We, the undersigned, hereby waive our rights to the 30-day advance notice and acknowledge that we have received a written explanation from the Board of Trustees describing our available pension payment options.

___________________________________________________________________________________ Participant’s Signature Date Participant’s Name (Please Print)

___________________________________________________________________________________ Spouse’s Signature Date Spouse’s Name (Please Print)

On the ____ day of ____________ 20___, before me came ____________________________ and

__________________________ known to me to be the persons described above, who executed the foregoing statement before me under oath.

Witnessed by:

____________________________________________________ Notary Public Date

-OR-

____________________________________________________ Union/Trust Fund Office Date Representative

____________________________________________________ (Please print name here)

AFFIX OFFICIAL SEAL OR UNION STAMP


UFCW–NORTHERN CALIFORNIA EMPLOYERS JOINT PENSION PLAN P. O. Box 4102 · Concord, CA 94524-4102 Telephone: (925)746-7530 · (800)552-2400

5020113v1/01961.001 19571407v.1

Relative Value Disclosure

IRS regulations require plans such as ours to give retiring participants a comparison of the relative values of the benefit payment options generally available under the plan. The aim is to help you make an informed choice about the form in which you receive your retirement benefits. “Relative value” means the actuarial present value of each optional form of payment relative to the Spouse’s Benefit (also called the “Qualified Joint and Survivor Annuity” or “QJSA”). For single people, the comparison is to the normal form of benefit, which is the Straight Life Annuity Option. The attached exhibit shows the relative values of the benefit payment options that the pension plan makes generally available to retiring participants. The options marked “AE” in the corresponding box are “Approximately Equivalent” to the QJSA.

In our case, all of the benefit payment options that are generally available to retiring married participants have approximately the same actuarial value, except for the 75% Joint & Survivor Annuity Option with respect to participants who are the same age as his or her spouse and who are retiring at ages 50, 55, 60, 65, or 70. The 75% Joint & Survivor Annuity Option has a significantly lower actuarial value than the benchmark QJSA, as shown in the attached table.

For unmarried participants, all available payment forms at the aforementioned ages will have approximately the same actuarial value. These conclusions are based on the valuation and reporting methodologies described in the IRS regulation, which can be found at Treas. Reg. Section 1.417(a)(3)-1. Upon your written request, we will provide you with a similar comparison based on your own age and estimated benefits, and on any other payment forms for which you are eligible.

As noted, the relative values are based on comparing the actuarial values of the benefit payment options to the actuarial value of the QJSA, also known as the normal form of benefit for married participants. Actuarial values of pension benefits are determined using mortality and interest assumptions. Mortality assumptions are based on standardized tables developed by actuarial organizations and life insurance companies, which analyze information about large groups of people to project the rates at which groups of individuals at different ages are expected to die. These statistical mortality projections are used to develop “average life expectancies.” The interest assumption is an estimate of the likely investment earnings, over time, on the money put aside to pay the benefits. This is relevant in the determination of actuarial values because investment earnings will provide some of the funds to pay the benefits.

Here the values were calculated, for comparison purposes, using an interest assumption and mortality table consistent with the minimum present values basis prescribed by Section 417(e) of the Internal Revenue Code.

It is important that you realize that this is not a guarantee or even a prediction of what you will actually receive after you retire. You should not rely upon it as if it were. The actual value of a stream of annuity payments for any individual, and its comparison to the values of different payment forms, will vary depending on how long the individual and spouse or beneficiary in fact live and on their ages when payments start. This is not the only information you should take into account when choosing your payment form for retirement. Other factors you might want to take into account in deciding how much a particular payment option is worth to you personally, in comparison to the other forms in which your pension can be paid, include your health, your other sources of retirement income, the resources available to your spouse or family after you die, availability of life insurance, etc. You may want to consult a financial advisor when you make this important decision.

To obtain an individual relative values estimate, please send a written request to the Plan at the address shown above.

5020113v1/01961.001 19571407v.1

Relative Values Chart for UFCW-Northern California Employers Joint Pension Plan

For unmarried participants, all available options are approximately equivalent in value.

Chart for Married Participants

Commencement Age

50% Joint & Survivor (“QJSA”)

75% Joint & Survivor (“QOSA”)

30 100% 97.3%

35 100% 96.6%

40 100% 95.7%

45 100% 94.6%

50 100% 93.5%(1)

55 100% 92.1%(1)

60 100% 90.7%

65 100% 89.3%

70 100% 88.0%

(1) Figure shown is for the “Golden 85” Unreduced Early Retirement. For Early Retirement, the relative value is 90.0% at age 50 and 90.2% at age 55.

UFCW – NORTHERN CALIFORNIA EMPLOYERS JOINT PENSION PLAN

P.O. BOX 4102 CONCORD, CA 94524-4102 TELEPHONE: (925) 746‐7530 (800) 552‐2400

Notice of Right to Defer Commencement of Benefits

Pension at Early vs. Normal Retirement Age: If you elect to retire on an Early Retirement Benefit, your benefit will be reduced by the factors provided for in the Plan (please refer to the Important Notice of Changes in Your Benefits document dated October 2011). Since the calculation of the Early Retirement Benefit reduction is based on your age when you retire, the closer you are to your Normal Retirement Age when you retire, the smaller the reduction. If you delay receiving your pension until you reach your Normal Retirement Age, your pension will not be reduced for your age.

Example: Ed, a Group 1 Member, is age 55 (60 months younger than his age 60 Normal Retirement Age) when he chooses to retire with an Early Retirement Benefit. His unreduced benefit, payable at his Normal Retirement Age, would be $1,000.00 per month. However, because he wants his pension to start at age 55, his benefit will be reduced to $626.20 per month (62.62% of $1,000.00 = $626.20).

Example: Bob, a Group 2 Member, is age 55 (120 months younger than his age 65 Normal Retirement Age) when he chooses to retire with an Early Retirement Benefit. His unreduced benefit, payable at his Normal Retirement Age, would be $1,000.00 per month. However, because he wants his pension to start at age 55, his benefit will be reduced to $371.40 per month (37.14% of $1,000.00 = $371.40).

Pension Delayed Beyond Normal Retirement Age: You have the right to defer your retirement benefit beyond your Normal Retirement Age but in no event beyond your required beginning date. Your

required beginning date is April 1st following the calendar year in which you reach age 70 ½. If you do not begin receiving your benefit by your required beginning date, you may be subject to a federal excise tax equal to 50% of the amount of tax that should have been paid, which would be in addition to any ordinary federal income taxes that are owed.

If you delay receiving your pension until after your Normal Retirement Age your monthly pension will be actuarially increased, as provided by the Plan, to account for each month after your Normal Retirement Age that you were not working in “Suspendible Service” (please refer to page 11 of your Summary Plan Description). The amount of the actuarial increase may vary from year to year, so we suggest that you contact the Trust Fund Office for more information when you are contemplating retirement. As an alternative, you may elect to receive “missed” payments, for the period between your Normal Retirement Age and when your pension begins, in the form of a lump sum payment that includes interest. The lump sum payment will not include amounts for months during which you worked in Suspendible Service.

“Suspendible Service” is employment before age 70 (in excess of 63 hours per month) with any employer, whether or not they contribute to the Plan, in the same industry and in the same trade or craft in the same geographic area covered by the Plan.

Example: Ed is entitled to a Normal Retirement Benefit of $1,000.00 at his Normal Retirement Age (in his case, age 60) but delays retiring until age 63 (36 months after his Normal Retirement

Age). In the first 20 of those 36 months, Ed was employed in “Suspendible Service.” Because of the delay, his pension will be increased by 1% for each month after age 60 that he was not employed in “Suspendible Service”. Thus, his benefit will be increased to $1,160.00 per month (1% x 16 months = 16% x $1,000.00= $160.00. $1,000.00 + $160.00 = $1,160.00). As an alternative, instead of receiving an increased benefit payable on a prospective basis, Ed could elect to receive a lump sum reflecting his “missed” payments ($16,000.00 for the 16 months, plus interest) and receive $1,000.00 per month going forward.

Adjustments for the 50% and 75% Joint and Survivor Annuity Payment Forms: The payment options available to you when you retire are explained in the Explanation of Payment Options document included with your application package. As discussed in that document, election of either the 50% or 75% Joint and Survivor Annuity results in your benefit being reduced so that the Plan can pay either a 50% or 75% survivor benefit to your eligible surviving spouse. Although your basic pension benefit increases if you defer its payment to a later date, the reduction for either of these payment forms is greater as you and your spouse are older.

For example, under the 50% Joint and Survivor Annuity, the adjustment percentage for a Participant and spouse who are both age 65 is 90.2%. If they were both age 55, it would be 93.1%.

Please refer to the Plan Document or Summary Plan Description and the Important Notice of Changes in Your Benefit or contact the Trust Fund Office for more information.

JPP 2015 Annual Re-employment Notice 15148187v.1




www.ufcwtrust.com

RE: UFCW – Northern California Employers Joint Pension Plan

Annual Notice on Re-Employment Restrictions – 2015

As you know, there are certain restrictions on the type of work that you can perform while receiving a

pension from this Plan. Employment that is in the same industry, in the same trade or craft and in the

same geographic area covered by the Plan is referred to as Suspendible Service. The geographic area

covered by the Plan includes all of California, Hawaii and Nevada.

The following rules apply to all retired participants, regardless of retirement date, effective February 1,

2005.

Before Age 70 Your pension benefit will be issued to you monthly as long as you do not work for more than 63 hours per

month in Suspendible Service. These restrictions apply whether or not you return to work at a Union

establishment. The only exception is if you are re-employed in vacation relief – see below for more information.

If You Return to Work in Suspendible Service You must notify the Trust Fund Office if you return to work in Suspendible Service (in excess of the 63 hours per month limit) and your benefit will be suspended one month for each month you worked in excess of 63 hours. If your pension benefit is suspended due to excess re-employment for an Employer

who contributes to this Pension Plan, the hours reported for those suspended months will be reviewed. If

additional Benefit Credits were earned during the months for which benefits were withheld, an additional

benefit amount for those Credits may be added to your original pension.

Vacation Relief The 63-hour monthly limit discussed above may only be exceeded if you return to work to replace an

employee on vacation. However, in any case you are not allowed to exceed 756 hours in a calendar year

(prorated during the year you retire). Employment in excess of 756 hours in a calendar year will result in

the withholding of one month of your benefit for each 63 hours or portion thereof by which your hours

exceeded 756 hours.

If you will be working as vacation relief, you must send written notice to the Trust Fund Office in

advance, prior to the first day of the month in which you intend to work. You will be sent a letter

confirming that we received your notice.

Age 70 and Over There are no re-employment limitations if you are age 70 or over.

Special Rule If You Retired After April 30, 2010 and before January 1, 2012 If you retired after April 30, 2010 but before January 1, 2012, and then work in Suspendible Service in

excess of 63 hours per month after January 1, 2012 and before receiving 36 monthly pension benefit

payments, upon your subsequent retirement, your entire benefit will be recalculated as if you had retired


JPP 2015 Annual Re-employment Notice 15148187v.1

under either the Preferred Schedule or Default Schedule, as applicable to you. You previously received a

notice describing these reductions.

If you retired during this period and become re-employed on or after January 1, 2012, you may call the

Trust Fund Office for more information.

If You Are Considering Re-Employment If you are returning to work and will be re-employed in excess of the limits, please be sure to notify the

Trust Fund Office right away so that your pension can be suspended on a timely basis. You must also

inform the Trust Fund Office when your suspendible employment has ended so that your pension can be

reinstated. If you become re-employed in Suspendible Service but do not report this information timely, the Trust Fund has the right to recover any resulting overpayment from your future pension benefits.

If You Have Questions

If you have a question about whether particular work would be considered Suspendible Service or any

other questions about re-employment, please contact the Pension Department at the Trust Fund Office.

1000 Burnett Avenue, Suite 110 • Concord, CA 94520-2000 Mail: P. O. Box 4102 • Concord, CA 94524-4102

Telephone: (925) 746-7530 • (800) 552-2400 • Facsimile: (925) 746-7552 www.ufcwtrust.com

NOTICE

December 2009

TO: PARTICIPANTS IN THE UFCW-NORTHERN CALIFORNIA EMPLOYERS JOINT

PENSION PLAN

RE: TERMINATION OF EMPLOYMENT AND ELIGIBILITY FOR RETIREMENT

BENEFITS

This notice contains important information about your eligibility for retirement benefits under

the UFCW-Northern California Employers Joint Pension Plan (Plan). Please read it carefully and

keep it with your Summary Plan Description and other Plan information.

RETIREMENT APPLICATION PROCEDURES

Beginning February 1, 2010, applications for retirement benefits must be received by the Trust

Fund Office no later than the month before the requested pension effective date (your Annuity

Starting Date). For example, if you intend to retire in April 2010 (and otherwise meet the

eligibility requirements) your fully completed application must be received at the Trust Fund

Office during the month of March 2010. Your Annuity Starting Date will be the first of the

month following the month in which your application is received, unless you have requested a

future date, in accordance with Plan rules. This rule does not apply if you qualify for and elect a

Retroactive Annuity Starting Date under the Plan.

TERMINATION OF EMPLOYMENT BEFORE NORMAL RETIREMENT AGE

If you are younger than Normal Retirement Age (as defined by the Plan), the law requires that

you terminate your employment before you can begin to receive pension benefits from the Plan.

Benefits cannot start unless you have the present intent to retire, which requires terminating any

and all employment with all Contributing Employers to the Plan. Therefore, in order to retire

before Normal Retirement Age, you cannot be employed by a Contributing Employer in any

capacity, whether or not the employment is covered by a collective bargaining agreement.

Beginning with applications received on or after February 1, 2010, if you are younger than

Normal Retirement Age you will not be eligible for retirement benefits if you work any hours for

any Contributing Employer in any capacity in the month in which your retirement benefits would

otherwise become effective. You will not receive any benefit payments and you will be required

to file a new application for retirement benefits once you have met all eligibility requirements in

order to receive your retirement benefits.


For example, if the Trust Fund Office receives your pension application in February 2010 and

you request an effective date of April 2010, your application will not be approved if you work

any hours in any capacity for a Contributing Employer in April. You will have to reapply when

you have terminated your employment and meet all other eligibility requirements.

If you meet the “termination of employment” rule and begin receiving benefits, and later return

to work, your benefits may be suspended under the Suspendible Service rules described below.

Please note that if you retire on or after your Normal Retirement Age, you are not required to

terminate your employment with a contributing employer prior to retiring, but your benefits may

still be suspended under the Suspendible Service rules.

SUSPENDIBLE SERVICE RULES

Whether you retire before or after Normal Retirement Age, the Plan restricts the number of hours

you can work for any employer, whether or not they contribute to the Plan, in the same industry

and in the same trade or craft in the geographic area covered by the Plan while you are receiving

pension benefits. Under the Plan, such work is defined as “Suspendible Service”.

If you work in Suspendible Service, your pension payment will be suspended for each month you

work in excess of 63 hours per month. Your benefit payments will resume when you are no

longer employed more than 63 hours per month. There is an exception for work in vacation

relief (up to 756 hours in a calendar year), provided you notify the Trust Fund Office in writing

in advance of the date you begin such employment. Please see your Summary Plan Description

or contact the Trust Fund Office for more information.

Once you reach age 70, your retirement benefits will not be suspended, no matter how many

hours you work. If your benefits are suspended before you reach age 70, they will no longer be

suspended beginning the first day of the month after the month in which you reach age 70.

JP Term of Employment 12/09 2

1000 burnett avenue, suite 110 concord, ca 94520-2000 · pdf file1000 burnett avenue, suite...

Documents