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08-15-95 CCM
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08-15-95 CCM
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SECTION 7 - PENSION PAYMENTS (For Lump Sum and Defined Contribution Plans only) <br />NAME <br />ENTRY <br />DATE <br />RETIREMENT <br />DATE <br />BENEFIT <br />PAID <br />SUPPLEMENTAL <br />BENEFIT PAID <br />TOTAL <br />CA/It's. loarikuso✓l <br />l✓W'r Ever7!�' <br />4Y <br />q7-,z-D <br />/,Ovo <br />�/3,057� <br />SECTION 8 <br />CERTIFICATION BY SECRETARY AND TREASURER OF RELIEF ASSOCIATION, <br />MUNICIPAL FIRE DEPARTMENT, OR INDEPENDENT NON-PROFIT FIREFIGHTING CORPORATION <br />ertify that to the best of our knowl ' ge d belief, the facts presented in this report are true and accurate. <br />SIGMA` OF SECRETARY OF RELIEF ASS0CWn0N DATE BUSINESS PHONE <br />SIGNATURE 6F TREASW= OF'RVLIEF ASSOCIATION DATE BUSINESS PHONE <br />��y,� <br />SIGNATURE +MUNICIPALC (If Independent Non -Profit Firefighting Corpora- D y E BUSINESS PHONE <br />tion the Municipal Clerk of the largest municipality in population contracting <br />with the Independent Non- Profit Firefighting Corporation must sign) <br />SIGNATURE OF SECRETARY OF INDEP. FIREFIGHTING CORP. (if applicable) DATE <br />BUSINESS PHONE <br />ATTESTATION REPORT OR AUDIT BY LICENSED OR CERTIFIED PUBLIC ACCOUNTANT <br />Associations with assets and liabilities under $200,000, pursuant to Minn. Sint. § 69.051 subd. la(b), an independent public <br />accountant shall examine the financial information included within the fmanciai section of this reporting form. The independent public <br />accountant shall attest to the financial information required by Minn, Stat. § 69.051 subd. la(a). the examination should be conducted <br />in accordance with standards established by the American Institute of Certified Public Accountants and should include such procedures <br />as prescribed by the Office of the State Auditor. The independent public accountant's attestation report must be submitted with this <br />reporting form. Your deadline to submit all information to the State Auditor is March 31st. <br />Associations with assets or liabilities equal to or greater than $200,000 must furnish audited financial statements prepared in <br />accordance with generally accepted accounting principles (including footnote disclosures) together with an Auditor's Opinion and an <br />Auditor's Report on Internal Control and Legal Compliance. The Auditor's opinions, and audited financial statements must be <br />submitted with this reporting form to constitute a complete file. Your deadline to submit all information to the State Auditor is June <br />30th. <br />NAME OF LICENSED/CERTIFIED PUBLIC ACCOUNTANT: U l Li f-f F{ ES C E f ✓ , G.7`.y , <br />STATE'LICENSE NUMBER: <br />• �i <br />ADDRESS OF LICENSED/CERTIFIED PUBLIC ACCOUNTANT: Z IOD % W i4 i rE .RE M! ALE. <br />PHONE NUMBER OF LICENSED/CERT. PUBLIC ACCOUNTANT: 770 — 9SaS <br />Please mail this form (after signatures) to: Office of the State Auditor - Pension Oversight <br />525 Park Street, Suite 400 <br />Saint Not, MN 55108 <br />
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