Certification of Final Payroll: Confirm Response 'Certification of Final Payroll: Submitted_Response Your response was submitted to OPERS 12/24/09 10:36 Page 1 of1 BEACHWOOD - 301200 Employee Name Employee SSN Employee Provided Termination Date Employer Code MERLE 0 12/31/2009 301208 1 SRF85 The employee will terminate (or has terminated) their covered Yes employmentEmployee's Job Title Mayor Safety Director Was this a law enforcement or public safety position, as defined No by the Final Earnable Salaryfiate 12/31/2009' 1 Final Reporting Period End Date 12/31/2009 Do you have an approved conversion plan on file with OPERS under which No this Employee will receive a payout? Retire/rehire that will be re-employed as of January 1. 2010 Comments to OPERS Reporting Method: Data Entry Form Type: Certification of Final Payroll Last Change_Date: 12124109 10:36 AM Last Change By: ebrey result in month, notify the OPERS Employer benefits; I. . 5.- When a retired elected or appointed official returns to" on this Form of the firstmonth of zemp A ected official is re-employed as Social Security Numbe .-Retired;. 0 to an Eliected employment tdlan that . loyrne_n_t. tiniely Er employer liability for overpaid benefits. If a retired el "Call Center at the number listed above immediately to prevent an confirmation must then be made on a Form SR-6E within 10 days. A ups' . 5- First Name Ml Last Name I 9 boAb=Wi Street oriMailing Address - App ?4902 MELDON Ecvb city State ZIP Code Bencnwoo Home Phone Number Work Phone Number Fax Phone Number lb4bY0lI lbA9Rl90l Rt xaalaeq E-mail Address - Beginning date of re-employment Title . . . - . . - SR-6E (Revised 1/09) An elected official receiving an age and service retirement benefit who is elected or appointed to the same position for the remainder of the term or the term immediately following retirement. Pleasemark c, or below. If re-employment occurs less thantwo months after the retirement allowance commences, the entire ret' ement benefit will beforfeited during these" two months. i a. The director of-the Board of Elections has been notified in writing, at least 90 days prior to the primary election for the next term, of the elected off_icial's intent to retire; - b..'The elected officialwas already retired at least 90 days prior to the general election. c..The appointing authority has been notified that the official was already retired or intendsto retire prior to-the end of the term. d. None of these apply. The pension portion of the elected official's benefit must be forfeited for the duration of employment." The annuity portion of the benefit' is suspended and will be paid in a lump sum upontermination o_f re~e_mployment. OPERS contributionsmust begin with the first date of . -service. - An elected official receiving an age and service retirement_ben'efit who is elected or appointed to a different elected office. If re-employment occurs less than two months after the retirement allowance commences, the entire retirement benefit will be forfeited during those two months. Anelected or appointed official receiving an OPERS disyabilityybenefit. contributions must' begin with the first date of service. Disability benefits will be terminated. . 1 Seelnext page 5 3 CITY. OFZ 25325 FAIRMOUNT BLVD O1--1'1o 4412.2 (216) 5.9241901 FAX (2.92) 292--1984 Mlxyon MERLE S. GORDEN November 20, 2009 Mr. David A. Pfaff Finance Director I I City of Beachwood 25325 Fairmount Blvd. Beachwood, OH 44122 Dear Mr. Pfaff: Please be advised pursuant to O.R.C. 145.38 (3) that I intend to retire from my office of Mayor of the City of Beachwood, Ohio before the end of my current term. I wish to then continue in my capacity as Mayor as rehired. Sincerely, . Merle S. Gorden, Mayor I City of Beaohwood August 3, 2009 . I Cuyahoga County Board of Elections 2925 Euclid Ave. Cleveland, OH 44115 To Whom It May Concern: Please be advised pursuant to O.R.C. 145.38 (3) that I intend to retire from my office of Mayor of the City of Beachwood, Ohio before the end of my current term. Sincerely, mtaz?a?g Merle S. Gorden Fr-1 GUS new compensation schedule will not be applicable to the curre INTRODUCED BY: Saul Eisen ORDINANCE NO.- 2008-160 AN ORDINANCE AMENDING ADJUST TI-IE COMPENSATION OF THE DIRECTOR WHEREAS, Article Section 3 of the Charter of the City of Beachwood as amended in November, 1994, now permits Council to amend the compensation schedule for the Mayor as necessary; and WHEREAS, pursuant to BCO Sectien 14101, the Mayor also serves as the City's Safety Director; and A - WHEREAS, on December 4, 2000, Council adopted Ordinance No. 2000-173 providing for compensation for the Office of Mayor; and - .2004, Council adopted Ordinance No. 2004-150 ORDINANCE NOS. 2000--173, 2004-150 AND 2005-49 TO I WHEREAS, on November 15, approving the Mayor's expenses to attend Mayor's Court training for a total amount not to . i . exceed $400.00; and 2 WHEREAS, on June 6, 2005, Council adopted Ordinance No. 2005-49 adjusting the compensation of the Mayor/Safety Director; and . has determined that it is necessary to adjust the future WHEREAS, the Council ayor and Safety Director; and compensation for the Office of the not become effective until January 1, 2.010, vvhich term for the Office of the Mayor, and therefore the nt Mayoral tenn. - WHEREAS, such adjustments vrou] is the commencement date for the next full NOW, THEREFORE, BE IT by the_Council of the City. of Beachwood, 1 County of Cuyahoga, and State of O.hio that: Section 1: . Council hereby amends Ordinance No: a'ndi2005--49, 1,2010, as follows: and any other applicable ordinances, to be effective .1 anuary . Elected Officials. (A) Annual Co1npensatio1i'fo1' the'Mayor effective Ianuary 1, 2010: $96,200.00. - I i . The 7Mayor's_salaryi January 1, 2011; and by an additional three and one half percent beyond the previous increase, effectiveianuary 1, 2012; and by an additionalthree and one half beyond the previous increase, effective January I 2013. Aniiua-l Compensation for the Safety Director effective .la1iuary I, 2.010: $62,200.00. . - shall increase by three and" one half percent (3.5 effective NO. 2008-160 (13) Section 2: terminate at the end of ti - time adininistrative employees 0 _This is in addition to th shall increase by three and one half percent effective January 1, 2011; and-by an additional three and onehalf percent beyond the previous increase, effective January 1, 20l2; and by an additional three and one half percent beyond the previous increase, effective January 1,2013. The Safety Director's salary. Annual Benefits for the Mayor':- receive medical and other benefits generally provided for full- the City, with the exception of longevity cave. Such benefits will include, but are not limited' to, an option of AD coverage, and short term radministrative employees of the City, cellular The Mayor shall compensation and sick 1 medical, life insurance wit disability benefits provided fo phone allowance at maximum all Salary Ordinance, _and the use of an automobile provided by the City. The Mayor shall receive three (3) weeks of paid vacation during the Mayor's first term of office; four (4) weeks of paid vacation during a second term of office; and five (5) weeks of paid vacation during a third or subsequent term of office. "Fringe Benefit" pension "pickup plan" and pay fifty or/Safety Director's mandatory pension contribution. articipate in the The City shall establish a percent of the May Mayor/Safety Director's ability to City's "Salary Reduction" pension "pickup plan". Travel expenses for official business of the City or the reimbursement of out--of- pocket expenses in excess of Five Hundred Dollars ($500.00) must be approved by Council, All expenses of any amount shall be related to official City business, be substantiated by receipts submitted to the shall be reasonable, and shall Finance Department. >>-Expenses of an out-of--town worksliop, seminar or convention will require advance approval by 'Council if such event involves more .t11anFive Hundred Dollars ($500.00) in total expenditures. Trays] }3xpen3e3't0 attend Mayor's Court Training, each year, is approved for a total not to exceed Five Hundred Dollars Gratuities received by the Mayor for the performance of marriages may be retained bythe Mayor, in addition to the compensation provided herein, No other benefits are provided for tlielvlayor unless approved by Council. hat this compensation schedule for the Mayor' shall Council further directs ayor on December 31, 2013. Furth_e1', 1e next term of the Office iall be amended to insert all salary ordinances of the City sl of such ordinances inconsistent herevvith are repealed. in Mayor of the City, and any par applicable part, excel until this new salary or: )l'l'l'1E1l.'Il.'l'lC existing salary ordinance for the Mayor Sl1E1llI'61'l1Ell1l_ in effect linance becomes effective on January 1, 2010.' owed per Section 2.8.3 of the Administrative- he above salary and benefits for the ORDINANCE NO. 2008~l 60 Cou-ncil finds and determi-nes that the decision to adjust the eonipensation by the members of Council, without the existing Office of the Mayor. ection 3: of the Office of Mayor for the next term was made solely any participation by, influence, or attempt toinfluence by Section 4: Council and its committees _relating to the pass action were in meetings open to the public where required by Ordinances of the City. . Consistent with Article Section I of the Charter, this ordinance all be read three times, and not be passed as an age of this legislationthat resulted in formal Chapter 105 of the Codified Section providing for compensation ofthe Mayor sh emergency" or urgent legislation. WI-IEREFORE, this Ordinance shall be in full force and effect from and after the earliest date permitted by law. Attest: I . I hereby certify this legislation was duly adopted on the day of - I anuary, 2009, and pre Section 8 of the Charter on the day of January, 2009. 71 41,6 Cleric Acknowledgment: I have neither approved potential conflict of interest; and therefore the same shall . provided in the Charter for such cas es. . ./mafia/gr - Mayor or disapproved this legislation when presented to n1e due to a become law in the manner' S. Gorden did not participate in any deliberations I The Clerk of Council notes that Mayor Merle preside over any meetings durin consicleration of or.in thepassage of this legislation, nor did _he this Ordinance. . I Clerk Pursuant to the provisions of the City'Cl1arter: Placed on First: Reacting: December I, 2008 Placed on Second Reading: December 15, 2008 . Placed on Tliird Reading Adopted: January 5, 2009 It is found and determined that all formal actions and deliberations of I sented to the Mayor for approval or rejection in accordance with Martin D. Arsham ORDINANCE AN ORDINANCE AMENDING ORDINANCE 1985-81 and 1985~92 TO INCREASE THE COM-PENSATION OR THE MAYOR AND COUNCIL MEMBERS. WHEREAS, the last legislation providing. an increase in compensation for the I office of Mayor and Council was adopted in 1985, effective January 1, 1988, and Ordinary inflationary increases have reduced the value of this.pay schedule over the past ten years, and WHEREAS, the City has significantly changed Over the past ten (10) years, and now requires that the Mayor work substantially full time, and the new Charterisignificantly increases the obligations of the President of Council after January 1998, the effective date for a Council increase in . tion,.including the requirement that the Council President will chair all Council compensa meetings, prepare agendas and other legislative work, and other Council members will also have an increase in responsibility, and . WHEREAS, the Charter of the City of Beachwood was amended in November, 1994, and permits Council to amend the compensation schedule for the Mayor as necessary, and Council intends hereby 'to increase the compensation for -the Mayor' effective at once and for the Council effective January. 1, 1998; NOW THEREFORE, BE IT ORDAINED by the -Council of the City or Beechwood, Co_unty of Cuyahoga, and State of Ohio; 1 Section 1. That the Charter, Article provides: -- Se.c..3. Salaries and Bonds; - 1. Salaries. . I Council shall establish, by ordinance, oramend as necessary, the (A) salary and compensationof -the Mayor,' Council and all officers and employees of the City. - - (B) An ordinance providing for the compensation of the Mayor and Council shall be read three (3) times and not be passed as an emergency or urgent legislation. I (C) may not amend its compensation-later than thirty (30) days - before the time for filing nominating petitions for a Council terrn. Such an amendment shall be effective for all Council persons on January 1, following the next regular Council election, two (2) years thereafter. Section 2. ORDINANCE No. 1995-70, That Council hereby amends Ordinances 1985-81 and 1985-92 and any other applicable Ordinances as follows: Elected Officials.. Annual compensation for the Mayor: I -'Mayor, if Safety Director $75,000.00 - Mayor, if not Safety Director (to -be re-set) 'Director, Council mayreduce the" Councilimembers - shed with the expectation that (1) the Mayor The salary for the Mayor is establi the Mayor will work substantially full time. will be the Safety Director and (2) In the 'event that The Mayor determines to appoint another person to be Safety Mayor's salary shall increase by 3% on January 1, 1996 and by 3% on January 1, 1997. Annual benefits for the Mayor. ive medical benefits provided for administrative employees 1' an" automobile which Council provides for the Mayor and Travel expenses for official business of the City or ll or eloe CtLl\.Uo0 ad 0 I . processed. Plan yearstart I slaw Employer City Home Phone CARE ACCOUNT - FLEXIBLE SPENDING AccouNT (FSA) I YES elect to cont'r'ibute (befo1'e taxes) lor the PLAN which is per pay period to fund my account that pays qualified out-of-pocket health care expenses that are not covered by my employer's health plan or any other health plan. N0 decline this option for this plan year and understand that I will lose all tax savings that could receive as a participant. OPTION 13 LIMITED FLEXIBLE SPENDING ACCOUNT (LFSA) Available only if you have an The LFSA is in addition to the HSA. lt's limited because you can only pay dental and vision expenses from this account. El YES I elect to contribute (before taxes) For the PLAN which is per payperiod to fund my account that pays qualified out-ol--pocket health care expenses that are not covered by my employer's health plan or any other health plan. NO decline this option for this plan year and that I will lose all tax savings that could receive as a participant. PENDENT CARE ACCOUNT This pays for day care expenses For a dependent child, adult or elder, so that you may work. Eligible services include: nursery school, nanny and/or before/alter school carethrough age' I2, day care For a disabled adult or child, elder day care for parent or dependent, day "camp through age I2. _l:l YES I elect" to contribute (befo1'e taxes} for the PLAN YEAR, which is per pay period to fund my account that pays qualified dependent day care or elder care expenses. E, NO decline this option for this plan yearand understand that will lose all tax savings that could receive as a participant. REEMENT TO SAVE TAXES ON Paervnums E. YES On the appropriate benefit enrollment form, have enrolled in certain employer--sponsorecl insurance benefits health insurance). understancl that my share of the premium for these employee benefits will automatically be paid with pre-tax dollars. I also understand that if my required contributions for these insurance benefits are increased or decreased while this agreement is in effect, my taxable income will automatically be acljusted to reflect that change. - Cl NO I decline this option for this plan yearand understand that will lose all tax savings that could receive as a participant. Please read the following before signing this enrollment form. My employer and I agree that my taxable income will be reduced each pay period during the year by an equal portion of the benefit elections (selected above) set forth and that qualified expenses will be paid on a tax-free basis. I understand that I may change my election in the event ofcertain changes in my status and that prior to the first day ofeach plan year, I will-be offered the opportunity to change my benefit election for the upcoming plan year. I acknowledge that I have received, read and understand the Summary Plan Description. I understand that the take care" Card is available to pay only qualified expenses. I understand that qualified expenses paid with the Card or any other form of reimbursement cannot be reimbursed by any other plan and that I will not seek reimbursement from any other source. In addition. the expenses for which reimbursement is sought will not be claimed as tax deductions. I understand that when using the take care" Card I must keep all receipts and that, on occasion, I may be asked for documentation of charges made with my Card. I also understand that if payment is made that is not for qualified expenses, I will repay my employer. For any expenses not repaid by me, I authorize my employer to deduct the amount from my paycheck (if permitted by state law). 57/ Ernployeesignature Date 9" Return completed form to your employer Your employer determines the maximum annual contribution limit for your plan, which cannot exceed $2,500 etiective per IRS rules. Confirm with your employer or check your summary plan description for the maximum annual contribution limit allowed for your plan. (Sen 2012) to 7n17raIu=_ nlr-ins. All reserved. Annual Fire Accreditation Awards Ceremony. INTRODUCED BY: Brian H. Linick ORDINANCE No. 2012-125 TRAVEL EXPENSES FOR THE MAYOR AN AUTHORIZIN ING THE THIRTEENTH ANNUAL FIRE ASSOCIATED WITH ATTEND WARDS CEREMONY AND DECLARING AN - ACCREDITATION ANNUAL A EMEGENCY. 06 of the Codified' Ordinances requires advance associated with the Mayor's attendance at an out- ch expenses will exceed Five Hundred Dollars WHEREAS, Section 131. approval by Council of any expense of-town convention or event if su and WHEREAS, Section 13l.06 also requires all expenses to be related to official City business, to be reasonable, and to be substanti Finance Department; and WHEREAS, the Thirteenth Annual Fire Accreditation Awards Ceremony ("Ceremony") will be held in Denver, Colorado on August 2, 2012; and WHEREAS, the City of Beachwood Fire Department will be honored at the Ceremony; and . WHEREAS, the Mayor has been invited to attend the Ceremony; and WHEREAS, this Council desires to approve travel expenses associated with the Mayor's attendance at the Ceremony. NOW, THEREFORE, BE IT ORDAINED by the Council of the City of Beachwood, County of Cuyahoga and State of Ohio, that: Section 1. Council hereby approves travel expenses, including airfare, hotel, meal and other incidental expenses, relating to All expenses shall be substantiated by receipts submitted to the Finance Department. It is found and determined that all formal actions and deliberations the passage of this legislation that resulted in the public where required by' Chapter 105 Section 2. of Council and its committees relating to formal action were in meetings open to- 'Codified Ordinances of the City. . I Section This Ordinance is hereby declared to be an urgent measure eace, health, or safety; and for the further reason immediately necessary for .the public that it is necessary to provide for the Mayor's timely attendance at the Thirteenth Annual Fire Accreditation Awards Ceremony. A - ated by receipts submitted to the the Mayor's attendance at the Thirteenth ORDINANCE NO. 2012-125 WHEREFORE, this Ordinance shall be in full force and effect from and after the earliest date permitted by law. - Attest: I hereby certify this legislation was duly adopted on the 16"' day of July, 2012, and presented to the Mayor for approval or rejection in accordance" with Article Section 8 of the Charter on the 17"' day of July, 2012. %79/ 9' 7m77/ /Wu f, A Cl?fk Ihave approved this legislation this 17"' day of July, 2012 and filed it with the Clerk. 1 mm X. Approval: Mayor ORDINANCE NC. 2008-160 (B) Section 2: terminate at the end of the all salary ordinances Mayor of the City, and any part of sucl1 ordinances inconsistent applicable part, except until this new salary or - phone all - retained by the Mayor", in addition to the comp The Safety Director's salary shall increase by three and one half percent an additional three and one half percent effective January 1, 2011.; and by ective January 1, 2012; and by an additional beyond the previous increase, eff three and one half percent beyond the previous increase, effective January 1, 2013. Annual Benefits for the Mayor: benefits generally provided for full- The Mayor shall receive medical and other with the exception of longevity time administrative employees of the City, ch benefits will include, but are not limited to, compensation and sick leave. Su option of AD coverage, and short medical, life- insurance with an disability benefits provided for administrative employees of the City, cellular owanoe at maximum allowed per Section 2.8.3 of the Administrative Salary Ordinance, and the use of an automobile provided by the City. The Mayor shall receive three (3)'weeks of paid vacation during the Mayor's first term of ation during a second term of office; and five (5) office; four (4) weeks of paid vac weeks of paid vacation during a third or subsequent term of office. "Fringe Benefit" pension "pickup plan" and pay fifty Safety Director's mandatory pension "contribution. The City shall establish a r/Safety Director's ability to participate in the percent of the Mayor/ This is in addition to the Mayo City's "Salary Reduction" pension "pickup plan". ial business of the City or the reimbursement of out-of- pocket expenses in excess of Five Hundred Dollars ($500.00) must be approved by Council. All expenses of any amount shall be related to official City business, shall be reasonable, and shall be substantiated by receipts submitted to the Finance Department. Expenses of an out-of-town Workshop, seminar or convention will require advance approval by Council if such event involves more tal expenditures. Travel Expenses to than Five Hundred Dollars ($500.00) in to attend Mayor's Court Training, each year, is approved for a total not to exceed Travel expenses for offic -Five Hundred Dollars - ved by the Mayor for the performance of marriages may be Gratuities recei ensation provided herein. No other benefits are provided for the Mayor unless approved by Council. 1 further directs that this compensation schedule for the Mayor shall on December 31, 2013-. Further, ove salary and benefits for the herewith are repealed in hat the existing salary ordinance for the Mayor shall remain in effect ve on January 1, 2010. Counci next term of the Office of the Mayor of the City shall be amended to insert the ab dinancebecomes effecti 'Pursuant to Ohio Revised Code 11 Acknowledgement of receipt of Auditor of State fraud reporting svstem information a public office shall provide information about the Ohio fraud--reporting system and the means of reporting fraud to each new employee upon employment with the public office. Each new employee has thirty days after beginning employment to confirm receipt of this information. - . - By signing below you are acknowledging that the City of Beachwood provided you information about the fraud--reporting system as described by Section of the Revised Code, and that you read and understand the information provided. You are also acknowledging you have received and read the information regarding Section 124.341 of the Revised Code and the protections your are provided as .a classified or 'unclassified employee if you use the before-mentioned fraud reporting system. ?E\r4d9l[ have read the information provided by my employer regarding the fraud--reporting system operated by the Ohio Auditor of State's office. I further state that the undersigned signature acknowledges receipt of this information. S. Mme PRINT NAME, TITLE, AND DEPARTMENT PLEASE SIGN NAME DATE Eric Brey From! Mayor Gorden Sent! Thursday, May 03, 2012 11:21 AM TO3 Eric Brey 5ubJect= RE: Amended Personnel Policy Section 5.20 PLEASE READ EMAIL AND REPLY Received. - Thank you. Merle. S. Gordan, Mo;/or .216-2924901 5-1 32.7; 4 .1 Like "us on Facebook Hi/ww.beachwoodohio.com 9'41.' .5-V E. iirra From: Eric Brey Sent: Monday, April 30, 2012 3:03 PM To: Mayor's Office; Law All; Finance All Bui Community Services All; James A. Doutt Subject: Amended Personnel Policy Section 5.20 PLEASE READ EMAIL AND REPLY Please Reply to this email toacimowledge receipt. Thank you in advance for your cooperation. The receipt of this email acknowledges receipt and understanding ofthis policy. It is suggested that you read this carefully and if necessary, print it for review. All of the policies/ procedures are located in the on-line policy manual located in the following drive location: 'City' on 'City--hall\Data' (Pz) Folder - Personnel Policy Manual There is a black binder that contains copies of the contents of the on-line policy manual available for viewing in your office. Please check with your department director as to the location of this binder. Department_Note: Please replace existing version of this policy in the policy binders inyour office. *3"/Vote for Union Employees. This Personnel Policy Manual contains policies nforall employees of the City of Beechwood with the exception of those employees exempted by law or reporting to independent boards or commissions that have not 1 lding,All; Fire All; Kelly" Bowen; Joel Edelstein; Mark Sechrist; Service All; A .: Eric Brey A From: To: Sent Subject: Your message To: Eric Brey Eric Brey Eric Brey Thursday, May 03, 2012 11:17 AM Read: Delivery Report for Mayor Gorden Subject: Delivery Report for Mayor Gorden - Sent: Thursday, May 03, 2012 11:12:08 AM Eastern Time (US Canada) was read on Thursday, May 03,2012 11:16:46 AM Eastern Time (US Canada). 1 Delivery Report Amended PersonnelPolicyysectilon 5.20 - PLEASE READ EMAIL AND REPLY From: Eric Brey To: Sent: 4/30/2012 3:03 PM This Rr:1:>cJri' Wiayoi' Gsorderi Submitted 4/30/2012 3203 PM The message was submitted. Group Expanded 4/30/2012 3203 PM Page 1 of 1 Mayor's Office;Law All;Finance Al|;Building Ali;Fire All;Kel|y Bowen;Joel Edelstein;Marl< Sechrist;Service All;Community The list of members of the group "Mayor's Office" was expanded so that the message can be delivered to each recipient. 'Delivered 4/30/2012 3:03 PM The message was successfully delivered. Close 'City Of Dc-:part1nent of Finance 2700 Richmond Road Beachwood, OH 44122 Phone: 216-292-1913 Fax: 216-292-1912 561:'. A11'/so//E10 0: I From: Fax: 957 -- Pages: _3 Phone Date: Re: CC: . 3. we . 333:'? {?35 . A slip"! 'ti. A Wmaft .599. Authorization for Release of Account Information Ohio retirement law prohibits the release of confidential account information to a third party unless written authorization is provided by the member or retiree. You or the third party must contact OPERS separately to request account information. Use this form to authorize the release of account information as described below. It cannot be used to initiate a request for information. This form will not authorize access to a member's or retiree's MBS account. Lb Date of Birth Month Day Social Security Number Last Name GOR First Name MI /Vi Street or Mailing Address Citv B:/tr HWU Apt. Number /2 ZIP Code ii'-lie State oil (3 Work Phone Number Cell Phone Number ca? Home Phone Number 6 6' E-mail Address .. -to ja cl. 1. fiat l: 3| . . 'income verification Service credit" Contributions Form 1099-R Earnable salary Disability medical records Breakdown of benefits Value of account Any/ all account information (written and oral) Estimate of retirement benefits Hm ml I as Mm; /i Jim at; .;r'r3 LL-2 {Revised 12/11) Turn over to complete Authorization . 1. Physician Attorney 521/ Authorized Agent First Name MI Last Name ALAN Street or Mailing Address 3iI555 AL va State ZIP Code City 0H Phone Number A Fax Phone Number 4#0r7;sqrir 2. E]Physician ]:[Attorney |:lAuthorized Agent' First Name MI Last Name Street or Mailing Address City State ZIP Code Phone Number Fax Phone Number .. permitted by Section 145.27, Ohio vised Code, and Ohio Admin. Code 145~1-61, I authorize the person(s) or firm(s) listed to request and receive the indicated information pertaining to my account with the Ohio Public Employees Retirement System. This authorization is "good (check one): 'Mor th Dav Yea For 60 days For 90 days :1 lndefinitely El Until If a date is not specified, the authorization will be good for 60 days from the date it was signed. I ask that you honor copies or faxed transmissions of this authorization form. I acknowledge that additionally the original must be sent to OPERS for its membershiprecords. I authorize OPERS to release the data indicated on this form to the person/organization indicated. I understand that I may provide written revocation of this authorization at any time prior to the authorization's expiration as provided above. I understand that medical records' can be released only to my physician, attorney, or agent or the Retirement Board's physician, per Ohio retirement law. Member Signature M. I Do not print or type name. . I I IDr.:nrienrI JOURNAL REPORT TIME O1/19f2012 12:83 NAME 216--292~l912 BRO2J2509E36 NO. DATE TIME FAX DURATION RESULT COMMENT #398 61/19 11:49 9l5148571081# 63 OK TX ECM BUSY: RESPONSE NG POOR LINE CONDITION OUT OF MEMORY CU COVER SHEET POL POLLING RET RETRIEVAL PC PC-FAX 05.0.0020 000.>> 2000 00000200 200000 . 200 E0 . - - .000. 000.0 .0 0 0.0.0000 .00. 0.: 00000 >00. .00_m000= .000 000 000000 :0 00.0. 000. E00 0.: 000: . 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Wz0000< >>z00z000 . .0000_0_:00 0 00 020000 0_000 0000 000300 x00 0.02 :05 0000. 0000000000 000 00> 00_0 200 000 000.00 .000 00__000 oz .00_0 00000 0050 >00 00 00.0 00000 >0 0000500 000 000 0000 00000000 00_m_> 000 _00000 00c__00_0 >_00 >00 0000. E00000 0000 00 00000 >00 000 0 r_0E_s _Um0000_00r_00 000_0_ >>z0000< 0z_0z0._m 0._00m._n_ my :0 0.v.0_ =05 00000000000000 000 000> 00_0 200. 000 00:00 00.: 00__000_ Ozfi 000000000 0000000 m>00 0.00: 0000000 0000 00. 00000 >00 00" 0000 000000 0000000000 00000 >0000 ._0000m >00 . .0.000_0_000 0 00 020000 0_000 000.0 x00. . .00_0 00000 00000 >00 00 00_0 0:000 >0 0000500 000 000 0000 00000006 0000 00000 0000000 >00 00.5 E00000 >00 0000 00 00000 >00 00 0 000000000 00 0.00_0 mm; Em": 0200004 uzazmam 000_x0.E I E00000. 050 0:5: 5. flulislunr .0000 .1 >00 .6 .02 0000.005 =00>00 00? 000 000 00 00._.0._0Eo0 E0000 O- 0 e_ 03 0 0 3000000 0001 000.0 0.0 0000 0j@0 0 _7d/fi__0E0 0.. 0 0.: .0 0 000.002 >0._000m ._0_00m 20.050 003 00.0 000000 2300:0020 .Z000 00000200 x000 @000 00.000000 00.0. 002000: 00.3 20 0 . 0 8000 0E 2000 0202000020 Vi 1 1. 1 From: Mayor Gorden To: Eric.Brey@beachwoodohio.com Date: 5/13/2010 2:06 PM Subject: Mayor Gorden opened Amended Personnel Policies -- Sections 2.9, 4.9, 6.1 Mayor Gorden opened Amended Personnei Policies - Sections 2.9, 4.9, 6.1 -i'i335fions 0 From: Mayor Gorden To: Eric.Brey@beachwoodohio.com Date: 3/30/2010 1:34 PM Subject: Mayor Gorden opened Amended Personnel Policies - Sections 4.1 4.6 Mayor Gorden opened Amended Personnel Policies -- Sections 4.1 4.6 Mayor - From: Mayor Gorden To: Eric.Brey@beachwoodohio.com Date: 1/27/2010 3:14 PM Subject: Mayor Gorden opened Personnel Policy Amendment Mayor Gorden opened Personnel Policy Amendment . - Mayor From: Mayor Gorden To: Eric.Brey@beachwoodohio.oom Date: 'l/27/2010 3:14 PM Subject: Mayor Gorden deleted Personnel Policy Amendment Mayor Gorden deleted Personnel Policy Amendment I Ohio Public Employees Retirement System OPERS 277 East Town Street -- Columbus. Ohio 43215-4642 - 1-800-222-7377 . Januan/12,2010 MERLE S. GORDEN SR 8584 24602 MELDON BLVD . BEACHWOOD OH 44122 Dear Merle S. Gordon: Your Traditional Pension Plan retirement application was received December 17, 2009. Unless you were paid for time you worked beyond the date indicated on your application for retirement, your benefit is effective on January 1, 2010. Your first benefit payment is due the first of the month for which the benefit is effective. Due to necessary processing, please allow a minimum of 30 days after January 12, 2010 for the release of your first benefit payment. Ohio PERS will send information on the health plan(s) available to you under separate cover. to Surviving Spouse Plan as your payment plan. This is a joint nt of an annuity to you as long as you live. In the event of tinue to your spouse for the remainder of his/her life. This der the Single Life Benefit Plan (Plan B). You have selected Life with 50% survivorship annuity providing forrthe payme your death one-ha_lf of the annuity would con annuity is less than the amount you could receive un If your beneficiary predeceases you, your benefit will be re-computed and paid to you under the Single Life Benefit Plan, as authorized by state law. If you later remarry, you have one yearfrom your date of remarriage to change your plan of payment to provide for your new spouse. You have 30 days from the date OPERS issues your first benefit payment to change your plan of payment, to change your Partial Lump Sum Option Payment (PLOP) amount or to select a PLOP. You also have 30 days from the date your financial institution receives your first benefit payment to withdraw your retirement application. if you decide not to retire, you must notify OPERS in writing and repay, by personal check or money order, the net benefit amount issued to your financial institution. If you have any questions, please feel free to contact us at 1-800-222-7377. Sincerely, Ohio PERS SRCONFIHM STATE OF OATH os OFFICE COUNTY or CUYAHOGA I, MERLE S. GORDEN, do solemnly swear that I will support the Constitution of the United States, the Constitution of the State of Ohio, and the Charter and Ordinances of the City of Beechwood, and that I will faithfully, honestly, and impartially discharge the duties as MAYOR for the City of Beechwood, State of Ohio, during my continuance in said office. MM if/Iherle S. Gorden SWORN TO before me and subscribed in my presence this DAY OF JANUARY, 2010. STEVEN M. DET Attorney at Law My Commission has no expiration date Section 147.03 O.R.C. Certification of Final Payroll: Confirm Response "ementrfiv 1 Certification of Final Payroll: Confirm Response Your response has been successfully submitted to OPERSI Current Step: Confirm Response CITY OF BEACHWOOD - 301200 Employee Provided Termination Date 12/31/2009 Employer Code 301208 Employee Name Employee SSN GORDEN. MERLE SRF85 The employee will terminate (or has terminated) their covered employment. Yes Employee's Job Title Mayor Safety Director Was this a law enforcement or public safety position, as defined No by the Final Earnable Salary Date 12/31/2009 Final Reporting Period End Date 12/31/2009 No Do you have an approved conversion plan on file with OPERS under which this Employeewill receive a payout? Retire/rehire that will be re-employed as of January 1, 2010 Comments to OPERS Reporting Method: Data Entry Form Type: Certification of Final Payroll Last change Date: 12/24/09 10:36 AM Last Change By: ebrey '1 Ifi A ORDINANCE NO. 2008-160 I INTRODUCED BY: Saul Eisen - approvin CE AMENDING ORDINANCE 2004-150 AND 2005-49 TO THE DIRECTOR A) of the Charter of the City of Beachwood as oil to amend the compensation schedule for the AN ORDINAN ADJUST THE COMPENSATION OF WHEREAS, Article Section 3 amended in November, 1994, now permits Conn Mayoras necessary; and WHEREAS, pursuant to BCO Section 141.01, the Mayor also serves as the City's Safety Director; and WHEREAS, on December 4, 2000, Council adopted Ordinance No. 2000-173 providing for compensation for the Office of Mayor; and pted Ordinance No. 2004-150 WHEREAS, on November 15, 2004, Council ado 1 amount not to the Mayor's expenses to attend Mayor's Court training for a tota exceed $400.00; and A A WHEREAS, on June 6, 2005, Council adopted Ordinance No. 2005-49 adjusting the compensation of the Mayor/Safety Director; and WHEREAS, the Council has determined that it is necessary to adjust the fiiture compensation for the Office of the Mayor and Safety Director; and WHEREAS, such adjustments would not become effective until January 1,2010, which is the commencement date for the next full term for the Office of the Mayor, and therefore the new compensation schedule will not be applicable to the current Mayoral term. NOW, THEREFORE, BE IT ORDAINED, by the Council of the City of Beachwood, C.ounty of Cuyahoga, and State of Ohio that: Council hereby amends Ordinance No. 2000-173, 2004-150, and 2005-49, Section 1: nces, to be effective January 1, 2010, as follows: and any other applicable ordina Elected Officials. (A) Annual Compensation for the Mayor effective January 1, 2010: $96,200.00. The Mayor's salary shall increase by three and one half percent (3.5 effective January 1, 2011; and by an additional three a11d one half percent beyond the previous "increase, effective January 1, 2012; and by an additional three and one half percent beyond the previous increase, effective January 1, 2013. Annual Compensation for the Safety Director effective January 1, 2010: $62,200.00. . A -2- ORDINANCE NO. 2008-160 hall increase by three and o11e half percent effective January 1, 2011; and by an additional three and one half percent beyond the previous increase, effective January 1, 2012; and by an additional three and one half percent beyond the previous increase, effective January 1,2013. The Safety Director's salary (B) Annual Benefits for the Mayor: The Mayor shall receive medical and other benefits generally provided for full- time administrative employees of the City, with the exception of longevity compensation and sick leave. Such benefits will include, but are not limited to, medical, life insurance with an option of AD coverage, and short term disability benefits provided for administrative employees of the City, cellular phone allowance at maximum allowed per Section 2.8.3 of the Administrative Salary Ordinance, and the use of an automobile provided by the City. The Mayor shall receive three (3) weeks of paid vacation during the Mayor's first term of office; four (4) weeks of paid vacation during a second term of office; and five (5) weeks of paid vacation during a third or subsequent term of office. The City shall establish a "Fringe Benefit" pension "pickup plan" and pay fifty percent of the Mayor/Safety Director's mandatory pension contribution. This is in addition to the Mayor/Safety Director's ability to participate in the City's "Salary Reduction" pension "pickup plan". Travel expenses for official business of the City or the reimbursement of out-of-- pocket expenses in excess of Five Hundred Dollars ($500.00) must be approved by Council. All expenses of any amount shall be related to official City business, shall be reasonable, and shall be substantiated by receipts submitted to the Finance Department. Expenses of an out-of-town workshop, seminar or convention will require advance approval by Council if such event involves more than-Five Hundred Dollars. ($500.00) in total expenditures. Travel Expenses to attend Mayor's Court Training, each year, is approved for a total not to exceed Five Hundred Dollars the performance of marriages may be" Gratuities received by the Mayor fo tion provided herein. - retained by the Mayor, in addition to the cornpensa No other benefits are provided for the Mayor unless approved by Council. Section 2: Council further directs that this compensation schedule for the Mayor shall terminate at the end of the next term of the Office of the Mayor on December 31 2013. Further, ded to insert the above salary and benefits for the all salary ordinances of the City shall be amen such ordinances inconsistent herewith are repealed in Mayor of the City, and any part 0 applicable part, except that the existing salary ordinance for the Mayor shall remain in effect until this new salary ordinance beconies effective on January 1, 2010.' . The Clerk of Council ORDINANCE NO. 2008-160 Council finds and determines that the decision to adjust the compensation Section 3: of the Office of Mayor for the next term was made solely by the members of Council, without any participation by, influence, or attempt to influence by the existing Office of the Mayor. Section 4: It is found and determined that all formal actions and deliberations of this legislation that resulted in formal Council and its committees relating to the passage 0 action were in meetings open to the public where require Ordinances of the City. (I by Chapter 105 of the Codified Section 1 of the Charter, this ordinance Section 5: _Consiste11t with Article be read three times, and not be passed as an providing for compensation of the Mayor shall emergency or urgent legislation. WHEREFORE, this Ordinance shall be in full force and effect from and after the earliest date permitted by law. Attest: I hereby certify this legislation was duly adopted on the day of January, 2009, and presented to the Mayor for approval or rejection in accordance with Article Section 8 of the Charter on the day of January, 2009. mi Cler Aclmowledgmeiitz I have neither approved nor disapproved this legislation when presented to me due to a potential conflict of interest; and therefore the same shall become law in 'the manner provided in the Charter for such cases. Mayor notes that Mayor Merle S. Gorden did not participate in any deliberations or in the passage of this legislation, nor did he preside over any meetings during consideration of this Ordinance. an Clerk Pursuant to the provisions of the City Charter: Placed on First Reading: December 1, 2008 Placed on Second Reading: December 15, 2008 Placed on Third Reading Adopted: January 5, 2009 NU. zoo:-49 BY: Melvin M. Jacobs AN ORDINANCE AMEND mo ORDINANCE NOS. 2000-173 AND 2004450 TO ADJUST THE COMPENSATION or run DIRECTOR (A) of the Charter of the City of Beechwood as WHEREAS, Article Section 3 (1) to amend the compensation schedule for the amended in November, 1994, now permits Council Mayor as necessary; and WHEREAS, on December 4, 2000, Council adopted Ordinance No. 2000-173 providing for compensation for the Office of Mayor; and 5, 2004, Council adopted Ordinance No. 2004-150 WHEREAS, on November 1 aining for a total amount not to proving the Mayor's expenses to attend Mayor's Court tr exceed $400.00; and . I WHEREAS, pursuant to ECO Section 141.0], the Mayor also servesuasithe City's Safety Director; and A . WHEREAS, the Council has determined that it is necessary to adjust the future compensation for the Office of the Mayor and Safety Director; and WHEREAS, such adjustments would not become effective until January 1, 2006, which is the commencement date for the next full term for the Office of the Mayor, and therefore the new compensation schedule will not be applicable to the current Mayoral term. . NOW, THEREFORE, BE IT ORDAINED, by the Council of the City of Beechwood, County of Cuyahoga, and State of Ohio that: cil- hereby amends Ordinance No. 2000-173 and 2004--150 and any Section 1: Coun ry 1, 2006, as follows: other applicable ordinances, to be effective Janua Elected Officials. (A) Annual Compensation for the Mayor effective January 1, 2006: $85,000.00. The Mayor's salary shall increase 2007; and by an additional threepercent beyond the previous increase, effective January 1, 2008; and by an additional three percent beyond the previous increase, effective January 1, 2009. Annual Compensation for the Safety Director effective January 1, "2006: $55,000.00. all increase by three percent effective The Safety Director's salary sh dditional three percent beyond the January 1, 2007; and by an a previous increase, effective January percent beyond the previous increase, effective January 1, 2009. by three percent effective January 1, 2008; and by an additional three ORDINANCE NO. 2005-49 (B) Annual Benefits for the Mayor: and other benefits generally provided for full- time administrative employees of the City, with the exception of longevity compensation and sick leave. Such benefits will include, but are not limited to, medical, life insurance with an option of AD coverage, and short term disability benefits provided for administrative employees of the City, and the use of an automobile provided by the City. The Mayor shall receive three (3) Weeks of paid vacation during the Mayor's first term of office; four (4) weeks of paid vacation during a second term of of paid vacation during a third or subsequent term of office. The Mayor shall receive medical 5 5 5 Travel expenses for official business of the City or the reimbursement of out-of- pocket expenses in excess of Five Hundred Dollars ($500.00) must be approved by Council. All expenses of any amount shall be related to official City business, shall be reasonable, and shall be substantiated by receipts submitted to the Finance Department. Expenses of an out-of-town workshop, seminar or convention will require advance approval by Council if such event involves more than Five Hundred Dollars ($500.00) $30079-9 in total expenditures. Travel Expenses to attend Mayor's Court Training, each year, is approved for a total not to exceed Five Hundred Dollars ($500.00) $499799, he performance of marriages may be Gratuities received by the Mayor for he compensation provided herein. retained by the Mayor, in addition to No other benefits are provided for the Mayor unless approved by Council. further directs that this compensation schedule for the Mayor shall Section 2: Council of the Office of the Mayor on December 31,2009. Further, terminate at the end of the next term all salary ordinances of the City sha Mayor of the City, and any part applicable part, except that the existing sa until this new salary ordinance becomes effective on January Section 3: Council finds and determines that the decision to adjust the compensation of the Office of Mayor for the next term was made solely by the members of Council, without any participation by, influence, or attempt to influence by the existing Office of the Mayor. of such ordinances inconsistent herewith are repealed in lary ordinance for the Mayor shall remain in effect 1,2006. It is found and determined that all formal actions and deliberations of ng to the passage of this legislation that resulted in formal by Chapter 105 of the Codified Section 4: Council and its committees relati action were in meetings open to the public where require Ordinances of the City. ection 1 of the Charter, this ordinance Section 5: Consistent with Article VH1, three times, and not be passed as an providing for compensation of the Mayor shall be rea emergency or urgent legislation. ll be amended to insert the above salary and benefits for the ORDINANCE NO. 2005-49 WHEREFORE, this Ordinance shall be in full force and effect from and after the earliest date permitted by law. 'Attest: I hereby certify this legislation was duly adopted on the 6th day of June, 2005, and presented to the Mayor for approval or rejection in accordance with Article Section 8 of the Charter on the 7th day of June, 2005. _d.aLZ //W2//Mtg . Acknowledgment: I have neither approved nor disapproved this legislatio potential conflict of interest; and therefore the same provided in the Charter for such cases. 9% /g Mayor Gorden did not participate in any deliberations The Clerk of Council notes that Mayor Merle S. I side over any meetings during consideration of or in the passage of this legislation, nor did he pre this Ordinance. . Clerk Pursuant to the provisions of the City Charter: Placed on First Reading: May 2, 2005 Placed on Second Reading: May 16,2005 Placed on Third Reading &'Adopted: June 6, 2005 when _presented to me due to a I hall become law in the 'manner Cell Phone UsagiPolicY Acknowledgement of Receipt I, at (.3 5. gou?d have received the City's new Cell Phone Usage Policy, A2006-01 and understand it is my responsibility to read" and abide by this policy. If I have any questions regarding this matter, I will inquire with my Department Director or the Finance Department. . /77_/xfli. I 441%. Signature . -xar>> I 3 E3 Elm" kg; . Date a, .5 . .- STATE OF OHIO OATH OF OFFICE 3 COUNTY OF CUYAHOGA do solemnly swear that I will support the Constitution of the of the State of Ohio, and the Charter and Ordinances of the City y, honestly, and impartially discharge the duties of of Ohio, during my continuance in said office. Merle S. Gordon I, MERLE S. GORDEN, United States, the Constitution of Beachwood, and that I will faithful] MAYOR for the City of Beachwood, State SWORN TO before me and subscr ibed in my presence this 3rd DAY OF JANUARY, 2006. 4 FORT DEARBORN LIFE E2/New Enrollment Cl Change FOTITI Insurance Company (R) Chicago, Illinois Administrative Offices: Downers Grove, Illinois I Cleveland, Ohio I Dallas, Texas EMPLOYER: lf group is sell-administered, submit enrollment form only if evidence of insurability is required. If group is n5t sell administered, submit enrollment iorin to us. EMPLOYEE NAME -- LAST FIRST MIDDLE iNiTiAi. sex DATE OF aiRTi-i OF HIRE (FULLTIME) C?orileri lY\erIe. 3- Mliito It~8-- l?ldS socIAi. seciinirv NO. (THIS is voun NO.) EARNINGS do was", JOB TITLE CLASS 2 Eitnnuai GFIOUP NOJACCOUNT No. LOCATION 0? eocit Of-\ COVERAGE Your non-medical group insurance program _may not include all the benefits listed below. Ask" your employer for the details cl whether you will be required to complete a health questionnaire. about the benefits available to you, your cost, if any, an BASIC Supplemental Life Supplemental Other Basic STD Benefit LTD Benefit Dependent Life I3 Add I3 El 091- Cl Add El Change El Del I3 Yes El N0 [gives BNO {fives i:iNo ayes i:iNo ijNO - - - (A)dd Total Amount A Voluntary Term Life: Employee El YES N0 Voluntary Term Life: Spouse El YES N0 Voluntary Term Life: Dependent Child(ren) V53 N0 Voluntary individual Plan YES El N0 Voluntary Family Plan YES N0 Voluntary Short-Term Disability El YES Cl N0 Voluntary Long-Term Disability YES N0 Voluntary Critical Illness with Cancer Benefit YES CI N0 Voluntary Critical Illness without Cancer Benefit CI YES N0 SPOUSE NAME - LAST FIRST M.i. sex SPOUSE DATE OF BIRTH . spouse sOciAi. SECURITY it (it applicant) [3 - Has Employee (if applicant) used cigarettes or other tobacco products Has spouse (if applicant) used cigarettes or other tobacco products in the |ast2 years? YES NO in the last 2 years? tj YES [1 NO Review the following guidelines which apply to voluntary coverage(s) - New Voluntary STD plans and benefit increases are subject to a 12/12 pre-existing condition limitation (3/12 in PA). - You may enroll, apply for additional coverage, or request a change to current voluntary benefits only during a scheduled EWOIIWGNI P9"0d- - Your Voluntary LTD benefit may not exceed 60% of your - Your weekly STD benefit may not exceed 60% of your basic basic earnings (excluding bonuses, overtime and any extra weekly earnings (excluding bonuses, overtime and any extra compensation other than commissions). Oihei than - New Voluntary LTD plans and benefit increases are subject to - if you are eligible for state-mandated temporary disability a condition limitation (12/12 in CO, MS, benefits, or any employer sponsored income replacement SC, MT, CT, 3/12 in PA). benefits, the combination of your state mandated benefit or . [f your earnings are based in whole or in part on Comm,-S-Sims other income benefit and your STD weekly benefit may not commissions will be averaged over the 12-month period prior exceed 60% of your basic weekly earnings. to the date disability begina BENEFICIARY DESIGNATION (For Employee Only: Must Be Completed if you have applied for life or insurance) If two or more primary beneficiaries are named, and you do not list benefit percentages, proceeds will be paid in equal shares to the named primary beneficiaries who survive you. if no primary beneficiary survives you, proceeds will be paid to the contingent beneficiary(ies). If you list (Employee is the beneficiary of proceeds from spouse or child coverage.) benefit percentages, the total must equal 100%. FIRST NAME LAST NAME I DATE OF BIRTH RELATIONSHIP . SOCIAL SECURITY BENEFIT . Gorrkeh ('1'-Ito wit': I loo Gotiux o1'- I9 I9 '7 I 30 Sosnl?. 3-< From: To: "Eric Brey" Date: 9/30/2005 10:19:39 AM Subject: RE: Public Safety Directors Classification Mr. Brey, I spoke with Bob Sayre our Membership Determination Officer and per the guidelines in the legislation, a person qualifies if their fulltime job is only as the Public Safety Director. Ron Culpepper Employer Outreach 888~400-0965 From: Eric Brey Sent: Tuesday, September 27, 2005 1:08 PM To: Employer Outreach Subject: RE: Public Safety Directors Classification Thank you. I look forward to hearing from you soon. "Employer Outrea Mr. Bey, Thank you for your question. i need to chekc for clarification from our Membership Determination Officer for a person who had dual roles: ch" 09/27 1:06 PM Ron Culpeper Employer Outreach 888-400-0965 From: Eric Brey Sent: Monday, September 26, 2005 4:09 PM To: Employer Outreach Subject: Public Safety Directors Classification If our elected, fulltime Mayor also serves as our safety director, is he effected by this? CONFIDENTIALITY NOTICE: The Ohio Public Employees Retirement System intends this e--mail message, and any attachments, to be used only by the person(s) or entity to which it is addressed. This message may contain confidential and/or legally privileged information. If the reader is not the intended recipient of this message or an employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that you are prohibited from printing, copying, storing, disseminating or distributing this communication. If you received this communication in error, please delete it from your computer and notify the sender by reply e-mail. CONFIDENTIALITY NOTICE: The Ohio Public Employees Retirement System intends this e-mail message, and any attachments, to be used only by the person(s) or entity to which it is addressed. This privileged information. If the reader is not the intended message may contain confidential and/or legally nt responsible for delivering the message to the intended recipient of this message or an employee or age recipient, you are hereby notified that you are prohibited from printing, copying, storing, disseminating or distributing this communication. If you received this communication in error, please delete it from your computer and notify the sender by reply e-mail. LA OPERS Ohio Public Employees Retirement System 277 East Town Street Columbus, Ohio 43215-4642 1-888-400-0965 February 1, 2005 3012 08 When repiying please give the number above This is used to identify your account in OPERS. ERIC A BREY CITY OF BEACHWOOD 2700 RICHMOND RD BEACHWDOO, OH 44122-1780 RE: Merie Gorden EARNINGS: $18,087.68 CONTRIBUTIONS: $1,537.45 RPT END DATE: 12/26/2004 The 12/26/2004 contribution report indicated unusuaiiy iarge earnings for the above empioyee. Please indicate the appropriate exgianation beiow, sign and Attention: CONTRIBUTION RECEIPTS DEPT. by return this form to the above address, Friday, March 4, 2005 to avoid notification to the empioyee This information is necessary to maintain the accuracy of the employee's account: a retirement or refund appiication cannot be processed without this information. Piease contact Empioyer Outreach at 1-888-400-0965 or e-maii us at empioyeroutreach@opers.org with any questions. 1. Three bi-weekiy payroiis during the reporting perdod. 2. Part-time empioyee who worked additionai hours or reguiar employee who worked overtime hours during the reporting period. Retroactive pay increase paid during the reporting period. The worksheet . on the reverse side must be completed. payment made during the reporting period. The worksheet on I the reverse side must be compieted. 5. Payment made in accordance with a settiement agreement, grievance judgment or court order. A copy of the supporting documentation must be submitted. If the payment was for actuai back wages the worksheet on the reverse side must be compieted. 2S 6. Annuai conversion payment for vacation sick or personai ieave. A copy of the pian is a) 2g on fiie with OPERS or b) enciosed. Contributions were withheid in error. A refund request has been forwarded to DPERS or b) enclosed. B. Other: Piease complete the worksheet on the reverse side at this form if any portion of the earnings in question should be aiiocated to other pay eriods. -5.75" 37/7 CERTIFYING OFFICER PHONE LARGE EARNINGS CAN NOW BE PROCESSED THROUGH THE OPERS EMPLOYER CONTRIBUTION SYSTEM (ECS). INITIATE REGISTRATION ONLINE AT WHH.OPERS.ORG. Form LE-1 From: Tina Turick To: David Pfaff Date: 12/4/2003 12:00:05 PM Subject: Mayor's 2004 Salary Thanks. Tina Please divide his salary equally among the 27 pays. OPERS Ohio Public Employees Retirement System 277 East Town Street Columbus, Ohio 43215-4642 1-888-400-0965 January 30. 2004 3o12 03 When replying please give the number above This is used to identify your account in OPERS. CITY OF BEACHWOOD 2700 RICHMOND RD BEACHWOOD, OH 44122-1780 RE: Merle Gorden EARNINGS: $19,446.40 CONTRIBUTIONS: $1,652.94 RPT END DATE: 12/28/2003 The 12/28/2003 contribution report indicated unusually large earnings for the above employee. Please indicate the appropriate explanation below, sign and return this form to the above address, Attention: Contribution Receipts Dept. by Monday, March 1, 2004 to avoid notification to the employee. This information is necessary to maintain the accuracy of the employee's account. 1. Three bi-weekly payrolls during the reporting period. 'Part-time employee who worked additional hours or regular employee who 2. worked overtime hours during the reporting period. 8. Retroactive pay increase paid during the-reporting period. The worksheet . 'on the reverse side must be completed. . 4. Disability payment made during the reporting period. The worksheet on the reverse side must be completed. Payment made in accordance with a settlement agreement, grievance judgment or court order. A copy of the supporting documentation must be submitted. If the payment was For actual back wages the worksheet on the reverse side must also be completed. 42$: 6. Annual conversion pay ent for vacation, sick or personal leave. of-the plan is a) on file with UPERS or b) enclosed. A copy A refund request a) has been 7. Contributions were withheld in error. forwarded to UPERS or b) is enclosed. 8. Other: Please complete the worksheet on the reverse side of this form if any portion of the earnings and contributions in question should be allocated to other pay periods. - Please contact Employer Outreach at 1-888-400-0965 or e--mail us at employergutreach@opers.org with any questions. J. 54/ /aw) 575 - 2,7/7 CERTIFYING OFFICER PHONE Form 01/2004) NOTE: Large earnings can now be processed through the OPERS Employer Contribution System (ECS). Initiate registration online at Standard Insurance Co. Group insurance Enrollment Form PLEASE Portland, Oregon Social Securitv Number Policy Number Suffix Employer Name (Policyowner) 64/, we Member Name (Last, First, MI.) . Ma|9 fi_Eirthdate Day Year Date Employed Workplace Location (State) 'Does Employer's Plan include: Eff. Date of insurance Mo "Day Year El Additional Life Dependent Life El Voluntary Mo Day Year 0,/lay o|,2 /0 EJOther 0,/lo,/0,2 Occupation Hours Worked Each Week Base Earnings From Hr. El Wk. ForThis Employer This Em loyer Mo. (Not incl. overtime) 5" /0 (.000.-W 7' Ct-hH'cn+ Te-rvV\ Complete for Life, and Additional Life coverages only. Give full name, address, and relationship of your beneficiary. Examples: i A. One Beneficiary Dorothy O. Smith, 777 America St., Anytown, USA 77777, Wife {not Mrs. John - - Smith) 4 - - B. Two Beneficiaries Peter Smith, Father, and Anna Smith, Mother, equally or the survivor C. Two Beneficiaries in Unequal Peter Smith, Father, three--fourths and Anna Smith, Mother, one-fourth Shares or the survivor D. One Primary and One Dorothy O. Smith, Wife, if living; otherwise Quincy Smith, Son Contingent Beneficiary E. One Primary and Two Dorothy O. Smith, Wife, if living; otherwise Quincy Smith, Son, and Mary Smith, Daughter, equally, or the survivor. Contingent Beneficiaries F. Trustee Dorothy O. Smith, Trustee under trust agreement dated G. |nsured's Estate My Estate -, - Do you know that if death occurs and a_ minor (a person not of legal age) or the insureds estate is the beneficiary it may be necessary to have a guardian or a legal representative appointed before any death benefit can be paid? This means legal Female Cl; /Mlo/,0 I fly If. expenses for the beneficiary and delay in the payment of the insurance. Please take this into consideration when naming . your beneficiary. Beneficiary - Complete for Life and Insurance . . Full Name, Address and Social Security it Relationship LU -FE P. ?cmisaxl. apply for Insurance under the-Group insurance Plan. I authorize deductions from my wages to cover my contribution, if required, toward the cost of my insurance. . -- Date 592-" Note: Beneficiary designation is not valid unless this card is signed gig dated. Policyowner _Use Only: (Use this area to record initial amounts as well as future changes) Dependents Voluntary Additional STD LTD Effective Date Class Amount Life Amount Amount Life Amount Benefitvolume Insured Earnings Group Administrator: Do not send this card to Standard unless asked to do so. Keep this card in yourfile. SI 18-2413-enlarged (7/98) OML GROUP ACCIDENT PLAN ENROLLMENT FORM EMPLOYEE COVERAGE . (Type or print only) Employee's" Name I 6:0 15 HEN 5 . Last Name I First Middle Initial Date of birth Address 5) 4'5 5/V/ell' Street City (Zone) State Municipality Name 6/ TV (0 Occupation with Municipality: Beneficiary I51 GEN ,/I?ilfl?/E7' Last Name First Relationship - WIFE COVERAGE (Complete if you wish to insure your wife) (Type or print only) I ~Wife's Name First Middle Initial - Last Name Date of birth Beneficiary Last Name First Relationship A. Complete this section ONLY if your duties and responsibilities place you in Group A. I EMPLOYEE COVERAGE: (Check One) Coverage $12,000 $24,000 $48,000 $72,000 $96,000 $120,000 El El El El Premium $0.70 $1.40 $2.80 $4.20 $5.60 $7.00 WIFE -COVERAGE: (Check One) 0 Coverage $12,000 $24,000 $36,000 $48,000 $60,000 . - I LEI Premium 350.70 $1.40 $2.10 $2.80 $3.50 B. Complete this section ONLY if your duties and responsibilities place you in Group B. EMPLOYEE COVERAGE . WIFE COVERAGE Cqverage - $12,000 Coverage $12,000 . at 1: Premium $1.10 Premium 350.70 (Sign two places) I hereby authorize the deduction of the required premium -rom my mm I hereby enroll in the plan. Date Employee Signature Date Employee Signature WAIVER This certifies that I do not wish to participate in the voluntary OML Group Accident Plan at this time. Date rirn hl hirnn .q'i_rrnn hn-n