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