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Member Census Information Request
Village of Springville Defined Benefit Service Award Prog am
For the Plan Year 1/1/2025 through 12/31/2025
Total
Name Date of Date of Past Current Credit
Last First Initial Birth Membership Service Service Earned
Dec}'1.1\)c:., \ AC.?) s},z..)1cr o ch,Jeoi 0 l t
ti f'. A P- A) '\C ) ,e '$/112()C1s1;;'2D1- C) 0 D
):::,·e r HA <::ft- C.nii.t ?:{29/11 1 6/2,/t..02!' 0 \ l
l1.:1t,!e:\::i<Vti'\tu :i,Re_7'T t/zl-f /J1s1 '2/z/wzs 0 \ l
('v[( .. ±l.!t )C. £ d.1...0 A(l.c:,\ off/ I3/It16 '-/I1 /2.02 /J 0 l I
7/5 L (1gS 1 zglzoZS
' I
/11; l;l "-() /\,"cho)A> {) CJ 0
.
Have there been any Plan Amendments? Yes/ Ifyes, please indicate any changes to the plan below:
Entitlement Age Effective Date
Benefit Formula: Amount Maximum Accrual Years Effective Ilate
Earning Past Entitlement Age: Yes/No Effective Date
Have there been any changes in Plan Trustee, Address, Telephone Number, etc.? Yes/iii,
If yes, please indicate the change(s) below:
Completed By:?rJ,riJ::JV/14JJ/J2{J f(L. ideiif
Title: Dat
1/12./2-0 2.