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Complete in <br />Trip Iicate <br />Employer's Ident. No, <br />blank) <br />(Please leave <br />ITEM <br />INSTRUCTION <br />PLEASE PRINT OR TYPE <br />;ITEM <br />City of South Bend, Department of Redevelop- <br />Show <br />full name of Employer <br />1246 County -City Bldg., 227 W. <br />men= <br />Street <br />Address <br />Jefferson Blvd. <br />South Bend, Indiana 46601 <br />City, <br />State, Zip code <br />_ <br />2 <br />Sow <br />date on which Employer's plan <br />Month Day <br />2 <br />year <br />ends . <br />' <br />December, 31 <br />effective date of Employer's <br />Month Day Year <br />3 <br />3 Sow <br />plan. <br />January <br />Immediate Eligibility (at <br />$' <br />employment with Employer, <br />I. <br />dicate requirements for Elig - <br />with no waiting period) <br />ility for coverage.(See Plan F^ <br />months of service (not <br />4 <br />4 <br />Art <br />i.cle III) <br />to exceed 12 months) <br />4 <br />Age (not to exceed 25), <br />3 <br />for employees first em ployed <br />4 after the effective date of <br />' <br />the Employer's plan. <br />; <br />Service with other Employers <br />participating in this Plan is to <br />=. <br />be included. <br />%o of all earnings (not to <br />Indicate <br />the percentage of earn- <br />tr. - <br />exceed 5%) <br />5 <br />5 <br />ings <br />to be contributed by Em- <br />loyer for each Participant. <br />a <br />� , <br />Earnings <br />means Participants' Earnings <br />"Plan "" <br />from <br />the Employer during a Year <br />(See <br />Plan section 4.1) <br />6 <br />indicate <br />by X whether Past Service <br />Past Service Credit <br />?6 <br />fi <br />Credit <br />is to be provided. <br />No Past Service Credit <br />5 <br />If <br />Past Service Credit is to be pro- <br />vided <br />hereunder, this amount is in <br />} <br />+� <br />addition <br />to amount specified in item <br />,'; <br />. <br />See Plan sections 1.10 and 4.2) <br />pJrvWCwWWa�Arrw+ra. +�'r.«u <br />� •s; <br />