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4K � A 0 . <br />ROSEVILLE FIREFIGHTERS' RELIEF ASSOCIATION <br />APPLICATION FOR-SECTION 44A, PENSION BENEFITS <br />(MUST BE RECEIVED BY ASSOCIATION WITHI <br />THIRTY (30) DAYS AFTER ATTAINING THE <br />AGE OF 50 YEARS) i <br />Claimant I s name <br />Claimant's current address <br />Address for mailing of benefits (if different from above) <br />Are you,now employed? <br />if "No", who was f ormer employer?. <br />By whom.? <br />%re you married? Spouse's full name and birthdate A <br />Date and place of marriage <br />dlist-depen"Ients and bir-th <br />at is your age Birth date <br />Date of separation from service <br />I hereby elect to receive distribution in Lump Sum - up to 3 <br />Annual Installments (strike inapplicable) and hereby acknowledge <br />9 <br />notice of waiver and I hereby waive any right or clalm to share in <br />any future 'increases in the pension benefits payable, if any. <br />If Installment elected: number of install - <br />ment s <br />