USVI Public Records

Document text

MEMBERSHIP RECORD To constitute a permanent record of the Employees Retirement System of the Government of the Virgin Islands and to be used in establishing the rights, privileges and benefits of employees participating in the System. The information to be given on this form is strictly confidential and is only for the use of the Retirement System. Please observe carefully the following instructions in completing this record. INSTRUCTIONS: 1. Please complete and print all information on the form. 2. State your full name. Do not use initials. A married woman should give her full maiden name as well as her married name. 3. No prior service credit can be granted until this form is completely filled out and filed with the System. When dates upon which employment began or was terminated cannot be given exactly, give the approximate date – for example, as "about September 1934"; or when the month is unknown "about 1921". 4. Include in the statement concerning prior service only the time during which you were actually employed by and were receiving pay from the Government or from the Federal Government in the Virgin Islands. Also exclude service for contractual work for the Government. 5. You may designate more than one person to be your beneficiary. GERS-BEN101 REV 06 GOVERNMENT EMPLOYEES RETIREMENT SYSTEM 3438 Kronprindsens Gade, GERS Complex - STE 1, St. Thomas, VI 00802-5750 • (340) 776-7703 • Fax (340) 776-4499 3005 Orange Grove, Lot #5, Christiansted, St. Croix, VI 00820-4313 • (340) 773-5480 • Fax (340) 773-5497 MEMBERSHIP RECORD CHECK LIST Please be sure to attach the following documents to your membership record: Social Security Card (copy) Birth Certificate Picture I.D. DD214 Military Form (if applicable) Beneficiary’s Social Security Number Beneficiary’s Date of Birth MEMBERSHIP RECORD TO: BOARD OF TRUSTEES EMPLOYEES RETIREMENT SYSTEM OF THE GOVERNMENT OF THE VIRGIN ISLANDS In order that my status in the Employees Retirement System of the Government of the Virgin Islands may be properly determined, I submit the following information: PERSONAL DATA 1. Name ______________________________________________________________________________________ (First) (Middle) (Last) ___________________________________________________________ (Maiden Name, if married woman) Employee No: ___________________________ Male K Female K Physical Address: ______________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Mailing Address: ______________________________________________________________________________________ ______________________________________________________________________________________ Work No. ______________________________________________________________________________________ Home No. ______________________________________________________________________________________ Cell No. ______________________________________________________________________________________ NOTE: Send notice to the System AT ONCE of any change of address so that the Board may be able to communicate with you whenever necessary. This is extremely important. 2. Social Security No. Date of Birth Current Age Place of Birth Month Day Year (Specify town and state or foreign Country) K Single K Married K Widowed K Divorced GERS-BEN101 REV 06 3. FAMILY DATA Members of Family Name Gender Date of Birth Social Security Number Your Husband or Wife Children 1. 2. 3. 4 5. 6. Father’s Name Alive Deceased Mother’s Name Alive Deceased 4. Have you any written or printed record showing your date of birth, such as a Birth Certificate, Passport or Naturalization Certificate? K Yes K No If the answer is "Yes", please submit copy to System _____________________________________________________________________ (Document Name) If the answer is "No", please take steps at once to obtain such a record since it will be required as additional proof of your age. SERVICE DATA 5. Name of Department in which now employed: ____________________________________________________________________ 6. Title of your present position: ______________________________________________________________________________________ 7. Present Rate of Pay: Bi-weekly Per Annum (without maintenance) $ $ Present Rate of Maintenance (if any) Nature of Maintenance Allowance: ___________________________________________________________________________________ 8. Date when employment in any Government Department began: _________________________________________________________ (m m) (d d) (y y y y) xxx K K K K GERS-BEN101 REV 06 9. List below all periods of employment in any department of the government, including service compensated on a "Per diem" or hourly basis, prior to the date stated in answer to Question 8; including also service in the Federal Government of the Virgin Islands. (Start with most recent employment) Name of Department Title of Position Rate of Pay Date of Date of in which employed: Amount Basis Appointment Termination Per (use separate line for (use separate line for Hour each title) each title) Month, Month Day Year Month Day Year Etc. 10. Do you intend to repay retirement refunds previously received from the Retirement System thereby regaining former service credit? K Yes K No CERTIFICATION: I HEREBY CERTIFY that the answers to questions 1 to 9 are true to the best of my knowledge, information and belief. __________________________________________ ____________________________________________________ (Date) (Signature of Employee) NOTE: Please name a beneficiary to receive the death benefits by completing the form on the next page. GERS-BEN101 REV 06 DESIGNATION OF BENEFICIARY J Active J Retiree Employee No. _____________________________ Social Security No. __________–________–______________ Telephone No. _____________________________ In accordance with the provisions of the law governing the Employees Retirement System of the Government of the Virgin Islands, I, ______________________________________________________________________ , designate the following as my beneficiary or beneficiaries in the event of my death: (1) ______________________________________ ________________________ ___________________________ ________________ (Print Name in full) (Beneficiary's date of birth) (Beneficiary's SSN) (Relationship) whose address is: ____________________________________________________________________________________________________________ (2) ______________________________________ ________________________ ___________________________ ________________ (Print Name in full) (Beneficiary's date of birth) (Beneficiary's SSN) (Relationship) whose address is: ____________________________________________________________________________________________________________ (3) ______________________________________ ________________________ ___________________________ ________________ (Print Name in full) (Beneficiary's date of birth) (Beneficiary's SSN) (Relationship) whose address is: ____________________________________________________________________________________________________________ (4) ______________________________________ ________________________ ___________________________ ________________ (Print Name in full) (Beneficiary's date of birth) (Beneficiary's SSN) (Relationship) whose address is: ____________________________________________________________________________________________________________ In the event the foregoing named person(s) do not survive me, my beneficiary shall be: (1) ______________________________________ ________________________ ___________________________ ________________ (Print Name in full) (Beneficiary's date of birth) (Beneficiary's SSN) (Relationship) whose address is: ____________________________________________________________________________________________________________ If more than one beneficiary is named, the benefit is to be paid equally or on the survivor basis. Any prior designation of beneficiary filed by me is hereby revoked. If the beneficiary or beneficiaries herein nominated shall not survive me and no other written nomination shall have been filed by me with the System, then the beneficiary shall be in the order named: (a) my spouse; (b) my children and descendants thereof by representation; or (c) my parents. The system is hereby requested and directed to make this designation a part of my Membership Record. Continued on the reverse side GERS-BEN101 REV 06 I reserve the right to change my beneficiary at any time by filing with the Board of Trustees of the Employees Retirement System of the Government of the Virgin Islands, written notice of such change, duly acknowledged before a Notary Public. _________________________________________________________________ ________________________________________________________________ Signature of Member Address ________________________________________________________________ City, State, Zip Territory of the U.S. Virgin Islands } District of } ss: On this ____________day of_____________________________ , before me personally appeared ________________________________, known to be the individual whose named is subscribed in the foregoing instrument and acknowledge that _________________________ executed the same as __________________________ free and voluntary act. __________________________________________________ Notary Public Commission Expires _______________________________ GERS-BEN101 REV 06