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DATA COLLECTION SHEET FOR <br /> SEPARATION ALLOWANCE BENEFIT <br /> (Article 12D of Chapter 143 N.C. General Statutes) <br /> <br /> F'lease provide inl'drmalion listed below as of December 31, 1989. This fitrm should be <br /> complclcd and relurncd by .hme 15, ! 9~)1} to avoid lale tee charged by acluary. <br /> <br /> COUNTY]CITY/¥OWN NAME: <br /> UNIT'S RETIREMENT SYSTEM I.D. NUMBER: (ir you know it) <br /> <br /> 1. Please list thc lotal number of employees covered by the sepamtkm allowaucc benefit. <br /> <br /> a. # of l.aw Enforcement Employees: <br /> b. t~ of Nou-Law Enforcement Employees: <br /> <br />2. List any rclired employees currcnlly rcceiviug sepan~tion allowances: <br /> <br /> MONTHLY DATE OF <br /> NAME SEPARATION BIRTH SEX <br /> ALLOWANCE MO/DAY/YEAR <br /> <br />.3. For those units ,'already funding thc separation allowance benefit, plcilse provide the £ollotving <br /> information as of December 31 1989: <br /> <br /> a. Book value Of bencril assets: ... <br /> b. Market value of bcncfh asscls: <br /> <br />[f yoahave questions about the form, please contact Don Ovcrholscr itl Buck Consuhams at <br />(404) 955-2488. <br /> NORTH C^ROLIHA ASSOCIATION <br />RETURN FORM BY JUNE 15 TO: OF COIJI'ITY COM MI.q. SIONEI'q~ <br /> <br /> P, O. Box !488 <br /> Rnlei.k'h, Norlh Carolina 27602 <br /> <br /> <br />