Form C4 - Application For Normal Retirement - 2011 Page 14

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CORRECTIONS OFFICER RETIREMENT PLAN

FORM C11A

Page 1 of 1

3010 E. Camelback Rd., Suite 200, Phoenix, Arizona 85016

(602)255-5575 FAX (602)296-2369

08/11

__________________

BENEFIT CALCULATIONS

(A.R.S. Section 38-781 as Amended)

USE THIS FORM TO CALCULATE NORMAL SERVICE RETIREMENT BENEFITS

* * * MEMBER MUST HAVE WORKED WITH EMPLOYER PRIOR TO CORP JOINDER DATE OF JULY 1, 1986 * * *

MEMBER'S NAME: _________________________________ EMPLOYER: ___________________________________

BIRTH DATE: _______/_______/_______

SOCIAL SECURITY NUMBER: _________-______-____________

SERVICE DATES: FROM _______/_______/_______ THROUGH _______/_______/_______

AMOUNT OF FINAL CONTRIBUTION MADE TO CORP $____________ FOR PAY PERIOD ENDING ____________

_______ years _______ days  365 days = ________________ years

Years of Service:

_______ years _______ days  365 days = ________________ years

Prior Service:

(_______) years (_______) days  365 days = (_______________) years

Less NON-CREDITED SERVICE:

_______ years _______ days  365 days = ________________ years

TOTAL LENGTH OF CREDITED SERVICE:

A. NORMAL RETIREMENT BENEFIT

1. BASE SALARY paid to member during a period of 36 consecutive months of credited service in which member

received highest base salary within the last 120 months of service:

YEAR

AMOUNT

YEAR

AMOUNT

______________ through ______________

$ __________________

_______________ through ______________

$ __________________

______________ through ______________

$ __________________

_______________ through ______________

$ __________________

______________ through ______________

$ __________________

_______________ through ______________

$ __________________

______________ through ______________

$ __________________

_______________ through ______________

$ __________________

2. Total amount of highest 36 consecutive months of base salary: . . . . . . . . . .. $_______________

3. Average monthly salary: . . . . . . . . . . . . . . . . . . . . . . . (A.2  36 months) = $_______________

4. Normal Retirement Benefits: 2% (.02) multiplied by years of credited service (include fractional years up to a

maximum of 37.5 years) . . . . . . . . . . . . . . . . . . . . (02 x _______ years) = $ _______________

5. TOTAL MONTHLY BENEFIT FOR NORMAL RETIREMENT: . . . . . . . . . . . . . . . . (A.3 x A.4) = $ _______________

6. Early Retirement factor

__________

x A.5 = $_______________

OPTION # 2 5-Year Certain Factor