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VOLUNTEER FIREFIGHTERS' RELIEF ASSOCIATION REPORTING FORM ANNUAL CORPORATE REGISTRATION FOR 1995 PENSION INFORMATION FOR THE YEAR ENDED DECEMBER 31, 1994 GENERAL INFORMATION: 1. CORPORA, E ^aA'2'(i'..'.: NU(X-L:3.: E-418 2, CORPORATE NAME: The Lake Elmo Firemen's Relief Association PLEASE READ ALL INFORMATION BELOW: INFORMATION FROM PART 1 OF THIS FORM IS PROVIDED TO THE OFFICE OF THE SECRETARY OF STATE AS CORPORATE REGISTRATION INFORMATION. 3. REGISTERED OFFICE ADDRESS: ITEMS 1-4, IF PRE-PRINTED, LIST INFORMATION +! CURRENTLY ON FILE WITH THE OFFICE OF THE Lake Elmo MN SECRETARY OF STATE. IF ITEMS 2-4 ARE NO LONGER CURRENT, YOU MUST COMPLETE AN AMENDMENT TO THE ARTICLES OF 4. REGISTERED AGENT (RL�QUIR'�U O\LY IF AN Af3ENT. CORPORATION. YOU MAY OBTAIN AN IS LISTED IN THE ORIGINAL Ar.T!'_LES OF AMENDMENT FORM BY CALLING (612) 296-2803. INCORPORATION OR SUBSEQL'FN T AMENDMENTS): THERE IS A $35.00 FEE FOR FILING AN AMENDMENT. YOU MUST LIST CURRENT INFORMATION FOR ITEMS 5-7. 5. ' NAME OF CORPORATE PRESIDENT: � Ouvlas f�i!A+� 6. NAME ANf5 TELEPHONE NUMBER OF CONTACT PERSON FOR THE CORPORATION: Chyj-5 #040acv-6� PHONE: (gX) -/30- 811-3 7. MAILING ADDRESS: 30co [avevh� � G�l� ��o �A4/ Ia FIRE DEPARTMENT INFORMATION. - THE FIRE DEPARTMENT YOUR AMC. IS AFFILIATED WITH IS A: MUNICIPAL FARE DEPARTMENT INDEPENDENT NON-PROFIT• FIREFIGHTING CORPORATION NUMBER OF ACTIVE MEMBERS IN YOUR FIRE DEPARTMENT RELIEF ASSOCIATION INFORMATION. — NO. OF ACTIVE MEMBERS IN THE RELIEF - NO. OF RETIRED/DISABLED RECEIVING BENEFITS 2 NO. OF RETIRED MEMBERS ON DEFERRED PENSIONS 31 TOTAL RELIEF MEMBERSHIP BENEFITS INFORMATION OTHER BENEFITS AMOUNT PER TYPE OF SERVICE PENSION BENEFIT: SHORT TERM DISABILITY $ + LUMP SUM LONG TERM DISABILITY $ / DEFINED CONTRIBUTION (SPLIT THE PIE) DEATHIFUNERAL BENEFIT $ + \. MONTHLY SERVICE PENSION'_ SURVIVOR BENEFTT $ SOOU— l nl�u 6c-- ,_ OTHER (SPECIFY)