HPR Application for Pension Benefits

Heating, Piping, and Refrigeration Pension Fund

Physical Address: 8700 Ashwood Dr. Suite 150, Capitol Heights, MD 20743 • Mailing Address: PO Box 21427 Eagan, MN 55121
Phone: (410) 444-3756 or (800) 618-2879 • Fax: (240) 303-2484• Website: HPRBenefitFunds.com

Administered by Welfare & Pension Administration Service, Inc.

APPLICATION FOR PENSION BENEFITS
Instructions
1. Please read each question carefully.
2. Answer all applicable questions. This will avoid delays in processing.
3. Attach photocopies of yours and current spouse’s proof of age and your marriage certificate.
4. If you have served in the Military, please provide a copy of your DD214. You may be entitled toadditional credits under the Federal Regulation USERRA, if you qualify.
5. Return the completed application and related documents so that they reach the Fund Office at least 30 days prior to the date you would like your Pension Payments to start.
Member's Personal Data
Name*

First NameMiddle InitialLast Name
Member Form Name
Home Street Address*
Street Separator
City*
City Separator
State*
State Separator
Zip Code*
Member Form Address
Social Security Number*
Home Phone Number*
Please enter a valid phone number.
Mobile Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Upload Your Proof of Age*

Cancelof

INSTRUCTIONS TO APPLICANT FOR RETIREMENT ABOUT PROOFS OF AGE

The acceptable proofs of age are listed below. Submit a photocopy of one of the proofs listed.

Proofs as high in order on the list as possible should be submitted, since the higher on the list your proofs of age, the more convincing they will be. Additional proof of age may be requested of you if the documents you submit do not constitute convincing proof of age.

A birth certificate.
A baptismal certificate or a statement as to the date of birth shown by a church record certified by the custodian of such record.
Document showing approval of Social Security Pension if age or date of birth is shown or proof of Medicare enrollment.
Notification of registration of birth in a public registry of vital statistics.
Certification of age by the United States Census Bureau.
Hospital birth record certified by the custodian of such record.
A foreign church or government record.
A signed statement by a physician or midwife, who was in attendance at birth, as to the date of birth shown on their record.
Naturalization record.
Immigration papers.
Military record.
Passport.
School record certified by the custodian of such record.
Vaccination record certified by the custodian of such record.
An insurance policy at least 15 years old.
Marriage record (application for marriage license of church certified by the custodian of such record or marriage certificate).
Confirmation record.
Other evidence such as voting records, driver's license, signed statements from persons who have knowledge of your date of birth.

NOTE: All documentation submitted as proof of age must clearly show your age to be acceptable. Also, if the name shown on the document differs from the present name, a copy of the court order or other document recording the name change should be submitted for identification purposes.

Marital Information
Are you CURRENTLY married?*

YesNo
Date of Marriage*

MonthDayYear
Date
Upload a Copy of Your Marriage Certificate*

Cancelof
Current Spouse's Name*

First NameMiddle NameLast Name
Spouse Form Name
Spouse's Social Security Number*
Current Spouse's Date of Birth*

MonthDayYear
Upload Your Spouse's Proof of Age*

Cancelof

INSTRUCTIONS TO APPLICANT FOR RETIREMENT ABOUT PROOFS OF AGE

The acceptable proofs of age are listed below. Submit a photocopy of one of the proofs listed.

A birth certificate.
A baptismal certificate or a statement as to the date of birth shown by a church record certified by the custodian of such record.
Document showing approval of Social Security Pension if age or date of birth is shown or proof of Medicare enrollment.
Notification of registration of birth in a public registry of vital statistics.
Certification of age by the United States Census Bureau.
Hospital birth record certified by the custodian of such record.
A foreign church or government record.
A signed statement by a physician or midwife, who was in attendance at birth, as to the date of birth shown on their record.
Naturalization record.
Immigration papers.
Military record.
Passport.
School record certified by the custodian of such record.
Vaccination record certified by the custodian of such record.
An insurance policy at least 15 years old.
Marriage record (application for marriage license of church certified by the custodian of such record or marriage certificate).
Confirmation record.
Other evidence such as voting records, driver's license, signed statements from persons who have knowledge of your date of birth.

Election of Pension Start Date
I want my pension payments to begin on the first day of
* *
Do you CURRENTLY receive Short Term Disability benefits from HPR Medical Fund?*

YesNo
Do you CURRENTLY receive Workers Compensation payments (for an injury incurred while working under this Plan)?*

YesNo

Election of Type of Pension

Regular Pension	For Participants who attain age 62 and are vested or who have been a Participant of the Plan for 5 full years.
Deferred Pension	For participants aged 55 or older who have NOT performed an hour of service on or after September 1, 1998, and who have at least 10 years of Vesting Service or 10 Pension Credits. Or For participants aged 55 or older who HAVE performed an hour of service on or after September 1, 1998, and who have at least 5 years of Vesting Service.
Early Retirement Pension	For participants aged 55 or older who HAVE performed an hour of service on or after September 1, 1998, and who have at least 5 years of Vesting Service.
Disability Pension	For a Participant who becomes totally and permanently disabled (as determined by the Social Security Administration), has at least 10 Pension Credits, and has worked under a Collective Bargaining Agreement or made self-contributions for at least 2000 hours within the Plan year in which the disability occurred and the two previous Plan years.

If eligible, I want to retire on a (select one)*

Regular PensionDeferred Vested PensionEarly Retirement PensionDisability Pension

Disability Pension
Date you first became disabled*

MonthDayYear
Date
Nature of your disability*
Have you APPLIED for a Social Security Disability Award?*

YesNo
Have you RECEIVED a Social Security Disability Award?*

YesNo
Upload a copy of your Social Security Disability Award*

Cancelof

Retirement Declaration
Generally speaking, pension benefits provided by the Plan shall commence only if the Participant has retired. To be considered retired, a Participant must be separated from all service with any and all Contributing Employers and from anyand all employment that would be considered to be Disqualifying Employment. However, Participants who have reached the Plan’s Normal Retirement Age (generally, age 62) and their Social Security normal retirement age (age 66 for many new applicants for benefits) are not required to separate from service to start their pensions.

To be considered separated from service and entitled to start a pension benefit, a Participant must have the bona fide intent to retire. A quick return to work after starting a pension shows that a bona fide intent to retire is lacking. A return to work within the first 90 days after a Participant’s pension effective date is considered very strong evidence that there was no bona fide intent to retire, and the pension would be voided, and the Participant would be required to return any money paid out to date.

Accordingly, I declare that I am retiring and will be bound by the requirements and rules stated in the Plan.

Further, I make the following declaration:
1. I have withdrawn from all employment with any employer obligated to contribute to the Heating, Piping and Refrigeration Pension Fund as of Date* . Name of last contributing employer: Employer Name*
2. I have withdrawn from all employment that would be considered Disqualifying Employment under the terms of the Plan (see description above).
3. I will refrain from further such employment, or I will notify the Trustees prior to my return to such work.
4. I will not work in employment covered by the Fund or in any employment defined as “Disqualifying Employment” under the Plan’s terms, except as permitted under the Plan.
5. I understand that if I violate these rules, I may be subject to the penalties stipulated in the Pension Plan Document.
Participant's Signature*

Clear
Date*

MonthDayYear
Date

Are you currently working and plan on continuing to work following retirement?*

YesNo
Statement of Employment while collecting Pension from the Heating, Piping and Refrigeration Pension Fund
In accordance with Section 7.07 of the Plan and Section 2530.203-3 of the Department of Labor regulations, payment of your pension will continue for only as long as you do not return to work in Disqualifying Employment. The Fund may, at any time, require proof from you of your continued entitlement to a pension benefit. We may also request information from your last employer regarding your separation from service. Rules on when you can work are as follows:

Disqualifying Employment before Normal Retirement Age (generally age 62) is any employment or self-employment in the type of work regularly performed by employees represented by the United Association of Journeymen and Apprentices of the Plumbing and Pipefitting Industry or one of its affiliated local unions, or any employment or self-employment in the plumbing, heating, piping and refrigeration industry for employers or businesses that are not signatory to a collective bargaining agreement with the United Association of Journeymen and Apprentices of the Plumbing and Pipefitting Industry of the United States and Canada or one of its affiliated local unions. Your retirement benefits will be suspended for any month you are employed in such work.

Disqualifying Employment after Normal Retirement Age (generally age 62). If a participant has reached Normal Retirement Age and earns more than the maximum allowed by Social Security without a reduction in benefits, his monthly benefit shall be suspended for any month in which he works or is paid for at least 40 hours in Disqualifying Employment. For this purpose, Disqualifying Employment is employment or self-employment in the heating, piping and refrigeration industry or any other industry covered by the Plan when your pension began, in an occupation in which you worked under the Plan, and in the geographical area covered by the Plan (Maryland, Virginia, the District of Columbia or any other state or province of Canada where contributions are required to be made by an employer to the Plan). If the Disqualifying Employment is for an employer or business that is not signatory to a collective bargaining agreement with the United Association of Journeymen and Apprentices of the Plumbing and Pipefitting Industry of the United States and Canada or one of its affiliated local unions, this subsection will be applied without regard to whether or not the Participants earns more than the maximum allowed by Social Security without a reduction in benefits

Disqualifying Employment after you attain your Social Security Normal Retirement Age. Once you attain your Social Security Normal Retirement Age (depending on your year of birth your SSNRA could be anywhere between age 66 and 67) you do not have to stop working to retire and can work as much as you like while collecting your pension benefits.

Please provide us with information on your current employment and/or information on any employment you expect to continue while collecting your pension benefits.
Employer Name*
Employer Street Address*
Street Separator
City*
City Separator
State*
State Separator
Zip Code*
Employer Form Address
Employment Start Date*

MonthDayYear
Employment Termination Date*

MonthDayYear
Job Responsibilities*

PLEASE NOTIFY THE FUND OFFICE OF ANY CHANGES IN YOUR EMPLOYMENT WHILE COLLECTING A PENSION FROM THE HEATING, PIPING & REFRIGERATION PENSION FUND.

Participant's Signature*

Clear
Date*

MonthDayYear
Date

Suspension of Benefits upon a Return to Work
In accordance with Section 7.07 of the Plan and Section 2530.203-3 of the Department of Labor regulations, payment of your pension will continue for only as long as you do not return to work in Disqualifying Employment. The Fund may, at any time, require proof from you of your continued entitlement to a pension benefit.

Disqualifying Employment before age 62 is any employment or self-employment in the type of work regularly performed by employees represented by the United Association of Journeymen and Apprentices of the Plumbing and Pipefitting Industry or one of its affiliated local unions, or any employment or self-employment in the plumbing, heating, piping and refrigeration industry for employers or businesses that are non-union; that is they are not signatory to a collective bargaining agreement with the United Association of Journeymen and Apprentices of the Plumbing and Pipefitting Industry of the United States and Canada or one of its affiliated local unions. Your retirement benefits will be suspended for any month you are employed in such work.

Disqualifying Employment after age 62 is employment or self-employment in the heating, piping and refrigeration industry or any other industry covered by the Plan when your pension began, in an occupation in which you worked under the Plan, and in the geographical area covered by the Plan (Maryland, Virginia, the District of Columbia or any other state or province of Canada where contributions are required to be made by an employer to the Plan).

After Normal Retirement Age (62-65), if you earn more in a year than is allowed by Social Security prior to a reduction in benefits, your monthly benefit will be suspended for any month in which you worked, or were paid, for at least 40 hours in Disqualifying Employment after you have reached the maximum amount.

Notwithstanding the above rule, if you engage in Disqualifying Employment for an employer or business that is not signatory to a collective bargaining agreement with the United Association of Journeymen and Apprentices in the Plumbing and Pipefitting Industry of the United Association of the United States and Canada or one of its affiliated local union, this subsection will be applied without regard to whether or not the Participant earns more than the maximum allowed by Social Security without a reduction in benefits.

You are required to notify the Fund Office, in writing, within 30 days after taking a job in Disqualifying Employment. If your benefits are suspended, you will be notified by personal delivery or first-class mail during the first calendar month in which payments are withheld. If you fail to give written notice within the 30-day period, or if you willfully misrepresent your return to Disqualifying Employment, your monthly benefit will be suspended for an additional six months. The six-month penalty does not apply after your 62nd birthday.

If you are not sure whether certain employment would be considered Disqualifying Employment, you may request the Fund to make a determination as to whether the employment you are considering would result in a suspension of your benefits. Such requests must be made in writing.

Once you stop working in Disqualifying Employment, you must again notify the Fund Office, in writing, of the date when such work ceased. Your pension will resume for the month after you stop this work, but there may be a delay of up to three months before your next check arrives.

If you receive a suspension notification from the Fund which you believe to be in error, you may make a written appeal requesting that the Trustees review this action. Your appeal must be in writing and must be made within 180 days of the notice of suspension.

I understand the above stated rules regarding Suspension of Benefits upon a Return to Work with Heating, Piping and Refrigeration Pension Fund. I will notify the Fund Office immediately if I return to work in employment, which is or may be considered prohibited.
Participant's Signature*

Clear
Date*

MonthDayYear
Date

Social Security Benefit Tests and Limits

	2019	2018
Wage Base for Social Security Tax	$132,900	$128,400
Wage Base for Medicare	No Limit	No Limit
COLA Increase	2.8%	2.0%
Social Security National Average Wage Index¹	$50,321.89 (for 2017)	$48,664.73 (for 2016)
Primary Insurance Amounts (PIA) Formula: First Bend	$926	$895
Primary Insurance Amounts (PIA) Formula: Second Bend	$5,583	$5,397
Maximum Social Security Benefit at Social Security Normal Retirement Age (SSNRA)	$2,861 month	$2,788 month
Earnings Test - Early Retirement (Age 62 thru SSRNA)²	$17,640 per year	$17,040 per year

(Once your wages total this amount you are limited to 40 hours per month or your benefits will be SUSPENDED)

Determining your Social Security Normal Retirement Age (SSNRA)

Retiring at Full Retirement Age – To Retire under Social Security you must have earned 40 credits. The below table will provide you with your Social Security Normal Retirement Age (SSNRA) based on your date of birth.

Year of Birth	Full Retirement Age
1937 or earlier	65
1938	65 and 2 months
1939	65 and 4 months
1940	65 and 6 months
1941	65 and 8 months
1942	65 and 10 months
1943-1954	66
1955	66 and 2 months
1956	66 and 6 months
1957	66 and 8 months
1958	66 and 10 months
1960	67

¹ This amount is not tied to the CPI but rather to earnings as reported to the SSA. The 2014 average (which is relevant for 2016) and background can be found on the SSA’s website.

² In the year of attaining SSNRA the early retirement earnings test is higher. In 2019, it will be $46,920/year ($3,910/month). After attaining SSNRA, individuals can receive their full benefits regardless of how much they earn.

I hereby apply for payment of a pension from the Heating, Piping and Refrigeration Pension Fund. The foregoing statements are true to the best of my knowledge and belief. I understand that a false statement may disqualify me for pension benefits and that the Board of Trustees of the Heating, Piping and Refrigeration Pension Plan shall have the right to recover any payments made to me because of a false statement.

I understand that this application can be cancelled by my written request at any time prior to the Retirement Date indicated above. I have fully read and understand the information furnished in the enclosed application.

Participant's Signature*

Clear
Date*

MonthDayYear
Date
Fund ID
Should be Empty:

Heating, Piping, and Refrigeration Pension Fund

APPLICATION FOR PENSION BENEFITS

Instructions

Member's Personal Data

Marital Information

Previous Marital Information

Election of Pension Start Date

Election of Type of Pension

Disability Pension

Retirement Declaration

Statement of Employment while collecting Pension from the Heating, Piping and Refrigeration Pension Fund

Suspension of Benefits upon a Return to Work

Social Security Benefit Tests and Limits

Determining your Social Security Normal Retirement Age (SSNRA)