Application For Retirement Pension Benefit

CENTRAL STATES SOUTHEAST AND SOUTHWEST AREAS PENSION FUND

APPLICATION FOR RETIREMENT PENSION BENEFIT
Dear Participant:
This Application for Retirement Pension Benefit packet is made up of the following forms – all of which must be completed and forwarded to the address shown below before you can be approved for a retirement pension benefit from the Pension Fund:
Pension Application Form/Background Information/Employment History • Please be sure to enclose copies of all appropriate documents (such as proof of age, marriage certificate, divorce decree, etc.).
Tax Withholding Form
Benefit Payment Method Form
Payment Options • Please do not complete the JSO Election or JSO Waiver more than 180 days before your retirement date S if you do, they cannot be accepted.
Retirement Declaration Form
We recommend that you complete the above forms and return them to us at least 90 days (but not more than 180 days), before your retirement date. By doing so, you will allow us the opportunity to review your eligibility status in advance and help us provide you with your first benefit check as close to your retirement date as possible.
All forms and documents should be submitted to the following address:
Central States, Southeast and Southwest Areas Pension Fund P.O. Box 5109
Des Plaines, IL 60017-5109
If you have any questions, please call us toll-free at 1-800-323-5000.

P.O. Box 5109 Des Plaines, Illinois 60017-5109 Phone: (800) 323-5000
G:\Groups\Funds\Forms\PN\PN Application-Pension.doc – 05/29/2008

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PENSION APPLICATION FORM/ BACKGROUND INFORMATION/EMPLOYMENT HISTORY

PRINT OR TYPE ALL INFORMATION

PARTICIPANT’S SOCIAL SECURITY NO.

LAST NAME

FIRST NAME

M. I.

SEX

IF FEMALE, MAIDEN NAME

ADDRESS E-MAIL ADDRESS

CITY

STATE

ZIP CODE

AREA CODE

(

)

PHONE NUMBER

MILITARY SERVICE

FROM

TO

MARITAL STATUS MARRIED SINGLE

WIDOWED DIVORCED

SPOUSE’S SOCIAL SECURITY NO.

DATE OF BIRTH
SPOUSE’S LAST NAME

MONTH / DAY / YEAR FIRST NAME

SPOUSE’S DATE OF BIRTH

MONTH / DAY / YEAR

RETIREMENT DATE

MONTH / DAY / YEAR

M.I.

IF FEMALE, MAIDEN NAME

DATE OF MARRIAGE

MONTH / DAY / YEAR

LIST CHILDREN’S COMPLETE INFORMATION
NAME

ADDRESS (City, State, ZIP Code)

BIRTHDAY MONTH / DAY / YEAR

RELATIONSHIP

LIST COVERAGE UNDER ANY OTHER TEAMSTER PENSION FUND AND/OR COMPANY PENSION PLAN
NAME OF FUND / COMPANY PLAN

CITY AND STATE

PERIOD OF COVERAGE FROM / TO

PLEASE INCLUDE COPIES OF THE FOLLOWING DOCUMENTATION WITH THIS APPLICATION AND MAIL IT TO THE ADDRESS SHOWN ON PAGE 4:
YOUR BIRTH CERTIFICATE (OR OTHER PROOF OF AGE) SPOUSE’S BIRTH CERTIFICATE (OR OTHER PROOF OF AGE) MARRIAGE CERTIFICATE DIVORCE DECREE
PLEASE NOTE THAT IF YOU DO NOT PROVIDE THE FUND WITH TIMELY NOTICE OF YOUR RETIREMENT, ANY RETROACTIVE BENEFIT PAYMENTS THAT YOU WOULD OTHERWISE BE ELIGIBLE TO RECEIVE ARE LIMITED TO THE 12-MONTH PERIOD PRIOR TO THE DATE THE FUND RECEIVES WRITTEN NOTIFICATION OF YOUR RETIREMENT DATE.
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LIST ALL EMPLOYMENT, REGARDLESS OF WHETHER IT PROVIDED FOR PARTICIPATION IN CENTRAL STATES PENSION FUND, BEGINNING WITH YOUR PRESENT OR MOST RECENT EMPLOYER. ADD ADDITIONAL PAGES FOR EMPLOYMENT HISTORY IF NEEDED.

NAME OF EMPLOYER EMPLOYER
TYPE OF WORK (BE SPECIFIC) REASON FOR LEAVING

ADDRESS OF EMPLOYER
ADDRESS CITY, STATE & ZIP

WORK COVERED BY TEAMSTER CONTRACT REQUIRING CONTRIBUTIONS TO CENTRAL STATES PENSION FUND?

PERIOD OF EMPLOYMENT
FROM / TO
FROM/TO

LOCAL UNION # AT TIME OF
EMPLOYMENT
LOCAL UNION #

COMPANY OUT OF BUSINESS?

YES

NO

YES

NO

EMPLOYER
TYPE OF WORK (BE SPECIFIC) REASON FOR LEAVING

ADDRESS CITY, STATE & ZIP

WORK COVERED BY TEAMSTER CONTRACT REQUIRING CONTRIBUTIONS TO CENTRAL STATES PENSION FUND?

FROM/TO

LOCAL UNION #

COMPANY OUT OF BUSINESS?

YES

NO

YES

NO

EMPLOYER
TYPE OF WORK (BE SPECIFIC) REASON FOR LEAVING

ADDRESS CITY, STATE & ZIP

WORK COVERED BY TEAMSTER CONTRACT REQUIRING CONTRIBUTIONS TO CENTRAL STATES PENSION FUND?

FROM/TO

LOCAL UNION #

COMPANY OUT OF BUSINESS?

YES

NO

YES

NO

EMPLOYER
TYPE OF WORK (BE SPECIFIC) REASON FOR LEAVING

ADDRESS CITY, STATE & ZIP

WORK COVERED BY TEAMSTER CONTRACT REQUIRING CONTRIBUTIONS TO CENTRAL STATES PENSION FUND?

FROM/TO

LOCAL UNION #

COMPANY OUT OF BUSINESS?

YES

NO

YES

NO

HAVE YOU EVER WORKED IN ANY OF THE FOLLOWING CAPACITIES WHILE A PARTICIPANT OF CENTRAL STATES PENSION FUND?

Manager/Supervisor

Self-employment

Owner/Operator OR

Had significant ownership (50% or more) in the company?

If yes, complete the following:

COMPANY NAME

PERIOD OF EMPLOYMENT FROM / TO

SITUATION (SEE ABOVE)

DID YOU HAVE THE RIGHT TO HIRE, FIRE, OR RECOMMEND IT? (CHECK ONE)

YES

NO

YES

NO

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OATH AND SIGNATURE I am applying for a pension benefit from Central States, Southeast and Southwest Areas Pension Fund. Under penalty of perjury, I certify that the information I have given in this application is true and correct to the best of my knowledge.

APPLICANT’S SIGNATURE

DATE

IMPORTANT INFORMATION REGARDING YOUR BENEFITS AND THE PENSION PROTECTION ACT
On March 24, 2008, the Pension Fund's actuary certified that the Pension Fund is in critical status under the Pension Protection Act (PPA), and notice of this fact was given to all participants on April 8, 2008. With respect to plans in critical status, the PPA creates a category of “adjustable benefits,” which generally includes all benefits other than a contribution based pension payable at age 65; these benefits may be eliminated or reduced in the future (even for participants that have retired and already begun receiving their pensions), largely depending on whether the participant’s employer (or former employer) continues to participate in the Pension Fund and agrees to a contribution schedule sufficient to maintain current benefits. Although the Pension Fund anticipates that the vast majority of bargaining units will elect a contribution schedule that keeps current benefits in place, because of the possibility of a reduction or elimination in benefits, you should weigh your decision to retire with care. In addition, under the PPA, the Pension Fund cannot guarantee that it will never be required to change its existing rules concerning adjustable benefits. However, in the event your adjustable benefits are reduced or eliminated in the future, you will receive a separate notice at least 30 days prior to the effect of any such benefit reduction.

RETURN TO:

CENTRAL STATES, SOUTHEAST AND SOUTHWEST AREAS PENSION FUND P.O. BOX 5109
DES PLAINES, IL 60017-5109

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TAX WITHHOLDING FORM
Note: Form W-4P is for U.S. citizens, resident aliens, or their estates who are recipients of pensions, annuities (including commercial annuities), and certain other deferred compensation. Use Form W-4P to tell payers the correct amount of federal income tax to withhold from your payment(s). You also may use Form W-4P to choose (a) not to have any income tax withheld from the payment (except for eligible rollover distributions, or payments to U.S. citizens delivered outside the United States or its possessions) or (b) to have an additional amount of tax withheld.
You may use the Pension Benefit Tax Withholding calculator on our website at www.centralstates.org to assist you in determining your tax withholding. If you have any questions, please consult your tax professional, or obtain a complete Form W-4P from the IRS for additional worksheets and instructions.
If you wish to make a tax election, please complete Form W-4P below.

FormW-4P
Department of the Treasury Internal Revenue Service
Type or print your full name

Withholding Certificate for Pension or Annuity Payments

Home address (number and street or rural route)

City or town, state, and ZIP code

OMB No. 1545-0415

Your social security number

:

:

:

:

Claim or identification number (if any) of your pension or annuity contract

N/A

Complete the following applicable lines:
1 Check here if you do not want any federal income tax withheld from your pension or annuity. (Do not complete lines 2 or 3.) . . "

2 Total number of allowances and marital status you are claiming for withholding from each periodic pension or annuity

payment. (You may also designate an additional dollar amount on line 3.) . . . . . . . . . . . . . . . . . .

Marital status:

Single

Married

Married, but withhold at higher “Single” rate

" _______ (Enter number of allowances)

3 Additional amount, if any, you want withheld from each pension or annuity payment. (Note. For periodic payments,
you cannot enter an amount here without entering the number (including zero) of allowances on line 2.) . . . . . . . . . " $______ (No pennies)

Your Signature "

Date "

If you are a nonresident alien and do not have a Social Security Number you may not use Form W-4P. Please write us at Central States Pension Fund, PO Box 5113, Des Plaines, IL 60017-5113 if this applies to you.

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***INSTRUCTIONS FOR COMPLETING FORM W-4P***
TO ELECT NOT TO HAVE FEDERAL TAXES WITHHELD FROM YOUR PENSION BENEFIT:
1. PRINT YOUR NAME, ADDRESS AND SOCIAL SECURITY NUMBER IN THE SPACE PROVIDED.
2. CHECK THE BOX IN LINE 1. 3. SIGN AND DATE THE ELECTION AND RETURN TO CENTRAL
STATES.
TO ELECT TO HAVE FEDERAL TAXES WITHHELD FROM YOUR PENSION BENEFIT (BASED ON IRS TAX TABLES):
1. PRINT YOUR NAME, ADDRESS AND SOCIAL SECURITY NUMBER IN THE SPACE PROVIDED.
2. CHECK ONE OF THE MARITAL STATUS OPTIONS AND COMPLETE THE NUMBER OF ALLOWANCES SECTION IN LINE 2.
3. YOU CAN DESIGNATE TO HAVE AN AMOUNT WITHHELD, IN ADDITION TO THE TAX TABLE AMOUNT, ON LINE 3.
4. SIGN AND DATE THE ELECTION AND RETURN TO CENTRAL STATES.
***Please note that the IRS does not allow for a specific ("flat") amount to be withheld. Therefore, tax withholding must be based on your marital status and number of allowances plus any additional amounts you wish to have withheld. If you need additional assistance or have any questions regarding Form W-4P, please consult your tax professional or see IRS Form W-4P for complete withholding instructions on pensions.
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------This Form Is Required To Initiate Your Pension Benefit Payments------
BENEFIT PAYMENT METHOD FORM
You can avoid worrying about when you will receive your pension check by using the Fund’s Electronic Funds Transfer (EFT) program. Under the EFT program your pension check is deposited electronically and automatically into your checking or savings account on the first day of each month (unless the first day of the month falls on a weekend or a banking holiday). IF YOU ARE ELIGIBLE FOR RETIREMENT BENEFITS, YOUR FIRST ONE OR TWO PENSION CHECKS WILL BE SENT TO YOUR MAILING ADDRESS AND SUBSEQUENT PAYMENTS WILL BE DEPOSITED ELECTRONICALLY INTO YOUR CHECKING OR SAVINGS ACCOUNT.

I hereby authorize the Central States, Southeast and Southwest Areas Pension Fund, and the financial institution shown below, to deposit my pension benefit directly into my account each month. If funds to which I am not entitled are deposited into my account, I/we authorize the Fund to direct the bank to return those funds and to provide any and all information in their records which may assist the Fund in the recovery of those funds including but not limited to the identity of all account holders. This authorization will remain in effect until I file a new authorization form or cancel my participation.

Signature:

Date:

Social Security Number:

Home Telephone Number:

Home Address:

City:

State:

Zip Code:

Bank Name:

Bank Address:

City

State:

Zip Code:

Type of Account:

Checking

Savings

Routing Number:

* Account Number:

IMPORTANT: In the space below attach a voided check or deposit slip with the correct bank routing and transit numbers.

ATTACH VOIDED CHECK OR DEPOSIT SLIP HERE

*9 DIGIT CODE IN THE LOWER LEFT CORNER OF CHECK OR DEPOSIT SLIP

I do not want electronic funds transfer and elect instead to have my benefit check sent to my mailing address each month. I
understand that my benefit checks will be mailed on the first day of each month and that my check may be delayed for
reasons beyond the Fund’s control and that there is no guaranteed delivery date. I further understand that in the event a check is lost the Fund cannot issue a replacement check until the 10th business day of the month.

Signature:

Date

Social Security Number:

IMPORTANT:

You must keep the Fund informed of any change in your address, regardless of which payment method you choose.

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PAYMENT OPTIONS
If you are single when you retire, your benefit will be paid as a single life annuity under the Lifetime Only Option or the Lifetime with Limited Surviving Spouse Option, depending on the Benefit Class you were at when you retired. If you are married when you retire, the normal form of payment is the Joint and 50% Surviving Spouse Option. The Joint and 50% Surviving Spouse Option provides for a reduced monthly payment for your lifetime so that in the event you die before your spouse, 50% of your reduced monthly benefit will continue to your spouse for the remainder of his or her lifetime. For those pension benefits effective on or after March 1, 2008, the Fund now offers an optional Joint and 75% Surviving Spouse Option form of payment. However, you will receive your retirement benefit in the form of the Joint and 50% Surviving Spouse Option unless you affirmatively elect the Joint and 75% Surviving Spouse Option or waive both Joint and Surviving Spouse Options. If you choose to waive both Joint and Surviving Spouse Options, we will require your spouse’s written, notarized consent as explained in the attached forms. Attached are the following forms, one of which must be completed and returned to Central States, Southeast and Southwest Areas Pension Fund, at the address below, before your retirement benefit can be paid. No form, Election or Waiver, that is signed more that 180 days prior to your retirement date will be accepted.
• ELECTION OF JOINT AND SURVIVING SPOUSE OPTION • WAIVER OF JOINT AND SURVIVING SPOUSE OPTION
(Including notarized spouse consent)
Central States, Southeast and Southwest Areas Pension Fund P.O. Box 5109
Des Plaines, IL 60017-5109
If you have any questions, please call us at 1-800-323-5000.
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ELECTION OF JOINT AND SURVIVING SPOUSE OPTION ("JSO PENSION")

Participant: Name: Spouse: Name:

Birth Date: Birth Date:

SS#: SS#:

I WISH TO RECEIVE MY RETIREMENT PENSION IN THE FORM OF THE JOINT AND SURVIVING SPOUSE OPTION (“JSO PENSION”), and CHECK ONE BOX:
I elect to have my spouse receive 50% of my pension benefits in the event of my death, OR I elect to have my spouse receive 75% of my pension benefits in the event of my death

I HAVE READ THE JSO PENSION EXPLANATION ON PAGE 8A, AND I UNDERSTAND THE FINANCIAL EFFECTS OF THIS SIGNED DOCUMENT ON MY PENSION BENEFIT, INCLUDING (BUT NOT LIMITED TO) THE FOLLOWING:
(1) The pension benefit that I would otherwise be eligible to receive will be adjusted to a lesser amount, on the basis of actuarial equivalence (as explained on Page 8a and in accordance with the accompanying JSO Pension adjustment charts), in order to provide a lifetime benefit to my spouse after my death.
(2) For purposes of this election, my “spouse” is the person to whom I am married on my “Effective Date” (the first day of the month following my retirement date), and in the event that I designated a retroactive retirement date, the person to whom I am still married on my “Initial Payment Date” (the date on which the Pension Fund first begins paying my retirement pension). Only the person who is my spouse on both my Effective Date and my Initial Payment Date is eligible to receive the survivor share of my JSO Pension.
(3) This election is revocable by me up until 90 days after my Initial Payment Date (the date on which the Pension Fund first begins paying my retirement pension) but cannot be later revoked or changed under any circumstances (except as indicated on page 8a). To be valid, revocation must be accomplished by completing and filing with the Fund the WAIVER OF JOINT AND SURVIVING SPOUSE OPTION form that has been furnished to me in this packet.

Participant Signature:

Date:

Spouse Signature:

Date:

SUBMIT COPIES OF YOUR MARRIAGE CERTIFICATE AND SPOUSE’S BIRTH CERTIFICATE WITH THIS ELECTION.

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EXPLANATION OF JOINT AND SURVIVING SPOUSE OPTION
Central States, Southeast and Southwest Areas Pension Fund ("Central States") provides you, as a Participant eligible to receive a lifetime monthly retirement pension, with an optional form of payment, called the Joint and Surviving Spouse Option ("JSO Pension"). If you elect the JSO Pension, your benefit amount will be less than the full retirement pension you have earned. This is because under the JSO Pension form of payment, benefits are paid for the longer of two lives (your and your spouse’s), and therefore your full benefit (which would otherwise be paid out for your lifetime only), must be actuarially reduced. This reduced JSO Pension amount (described below) is paid for your lifetime and upon your death, if that same spouse survives you, he or she will receive a monthly survivor pension (equal to 50% or 75% of your reduced JSO Pension amount) for the rest of his or her life - even if he or she later remarries. The difference between your full retirement pension benefit (which is the amount payable to you if you waive the JSO Pension form of payment and your spouse consents to that waiver) and your JSO Pension amount is determined by (1) your choice of either the 50% or 75% surviving spouse benefit, and (2) your age and your spouse’s age on your retirement date. The accompanying charts outline the various adjustment factors.
Federal law requires that if you are married when your retirement pension begins to be paid (your “Initial Payment Date”), to the same person you were married to on the first day for which your retirement pension is payable (your “Effective Date”), your monthly pension must be distributed in the JSO Pension form of payment unless both you and your spouse sign and file with Central States a valid and timely waiver of that option, witnessed and confirmed by a notary public.
Description of the JSO Pension
Reduced JSO Pension Amount. Central States will inform you, upon request, of the amount of your full retirement pension payable at your selected Retirement Date (this full pension is the unreduced lifetime amount payable to you if you waive the JSO Pension and your spouse consents to that waiver).
In addition, Central States will, upon request, provide written confirmation of your reduced 50% or 75% JSO Pension amount.
Effect on Your Spouse of a Waiver of the JSO Pension. If you and your spouse file with Central States a valid, timely and jointly signed JSO Pension waiver and, while receiving your full retirement pension, you die and are survived by your spouse, your spouse will not receive any further benefits from Central States unless (1) you earned at least 20 years of Service Credit (of which at least 10 years is based on Contributions), and you attained age 50 before leaving active participation in Central States Pension Fund, or (2) you qualified for a 25-And-Out or 30-And-Out Pension. If you meet the above criteria, your spouse will receive (a) the remainder (if any) of the first 60 months of payments of your full retirement pension if you retired at Benefit Class 4 or higher, or (b) a single $1,000 payment if you retired at Benefit Class 3A or lower.
Identification of Your Spouse. For all JSO Pension purposes, your "spouse" is the person to whom you are married both on the date on which your retirement pension actually begins to be paid to you ("Initial Payment Date") and on the first day for which your retirement pension is payable (“Effective Date”). Thus, if you elect a retroactive Retirement Date and as a result you receive a single retroactive payment of all monthly benefits due from your Effective Date to your Initial Payment Date, only the person who is your spouse, both on your Initial Payment Date and on your retroactive Effective Date, is (1) eligible to receive the survivor share of your JSO Pension (if the JSO Pension is elected), or (2) authorized to consent to your waiver of your JSO Pension (if the JSO Pension is waived), unless a qualified domestic relations order requires otherwise.
Election Period: Waiver of JSO Pension. To be valid and effective, your and your spouse's jointly signed waiver of the JSO Pension, duly notarized, must be filed with Central States within an election period that begins 180 days before your Effective Date and ends 90 days after your Initial Payment Date. Mail your jointly signed (and notarized) waiver of the JSO Pension to: Central States, Southeast and Southwest Areas Pension Fund, P.O. Box 5109, Des Plaines, IL 60017-5109. You may also later send to Central States (P.O. Box 5109, Des Plaines, IL 60017-5109), within the same election period, your signed revocation of a previously submitted JSO Pension waiver. No changes to your pension payment form and amount can be made after that election period expires (except as noted in the next paragraph).
Increase of JSO Pension Amount After Subsequent Death or Divorce of Your Spouse. If you are receiving a JSO Pension and your spouse (for JSO Pension purposes) dies first, your reduced JSO Pension will be increased to your full retirement pension the month after your spouse's death. Or, if you are receiving a JSO Pension and your spouse (for JSO Pension purposes) executes a specific written waiver of all rights to and interest in your JSO Pension, and if that waiver is incorporated in a court-approved property settlement agreement that is part of a judgment or order entered by a court of competent jurisdiction in a divorce, marriage dissolution or marital separation proceeding, your reduced JSO Pension will be increased to your full retirement pension the month after that judgment or order is entered.
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