Date of Birth - -     Employee #     

  Service Time years and  months     or  Membership Date - -

  Annuity balance ending prior year $   Bi-weekly deductions (avg.) $  

  Approximate Average Salary (of highest consecutive three years) $

  Group 1 (All Regular Employees)                    Vet Status Not a veteran    Veteran
  Group 4 (Police Officers and Firefighters)

Spouse (or former who hasn't remarried), child, parent or sibling -   Date of Birth  - -
Exclude from estimate