ATTACHMENT G RESPONDENT JOHNSON’S EXHIBITS … · requesting that Lee Turner Johnson be named as the beneficiary of ... instruction on retirement ... 2 beneficiary. His December

ATTACHMENT G

RESPONDENT JOHNSON’S EXHIBITS FROM THE ADMINISTRATIVE HEARING

~.\ ,/1 f~ KERSHAW I cu rm , & Rhf INOFF j tLP

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VIA FAX AND MAIL

Ms. Preet Kaur CALIFORNIA PUBLIC EMPLOYEES'

RETIREMENT SYSTEM

Legal Office P.O. Box 942707 Sacramento, CA 94229-2707

September 25, 2015

Re: In the Matter of the Appeal Regarding Death Benefits Payable Upon Death of GRANTLAND LEE JOHNSON by LEE TURNER JOHNSON, Respondent; Ref No. 2015-0373

Dear Ms. Kaur:

Pursuant to the General Procedures for Administrati ve Hearings for the California Public Employees' Retirement System ("CalPERS") and my September 21, 2015 letter to you, I am writing on behalf of Respondent Lee Turner Johnson to raise several significant issues, statements and communications between CalPERS and Lee Turner Johnson that have been omitted from the Statement of Issues, including but not limited to:

• Express statements contained in Grantland Johnson's June 23, 2014 letter to CalPERS requesting that Lee Turner Johnson be named as the beneficiary of his "CalPERS retirement ... Upon receipt of th[e] final settlement agreement, please immediately change all of my retirement benefit[s] ... to my wife, Dr. Lee Turner Johnson";

• Lee T urner Johnson's telephone conversation with CalPERS on or around August 5, 20 14 during which she: informed CalPERS that Grantland Johnson was in the Intensive Care Unit ("ICU"), had been there for over twenty days and was dying; sought clarification for completing the Application to Modify Option and/or Life Option Beneficiary form to designate her as his beneficiary for lifetime monthly benefits; was not informed that any additional form would need to be completed and submitted to finalize that process; and was told by CalPERS "not to worry, [Grantland Johnson's] wishes will be honored, no matter what," or a representation to that effect;

• References to Grantland Johnson's hospitalization, medical condition and overall health over the period when he and Lee Turner Johnson were researching,

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Attachment G Respondent's Exhibit A Page 1 of 3

Ms. Preet Kaur CALIFORNIA PUBLIC EMPLOYEES' RETIREMENT SYSTEM September 25, 2015 Page 2

completing, communicating with CalPERS about, and submitting forms and documentation for purposes of designating Lee Turner Johnson as beneficiary for Grantland Johnson's lifetime monthly benefits;

• The fact that CalPERS did not respond to Grantland Johnson's June 23, 2014 letter or otherwise communicate with Grantland Johnson regarding his requests for nearly a month. The next communications from CalPERS were through letters, dated July 25, 2014 and August 14, 2014. The July 25, 2014 letter only enclosed a Post Retirement Lump Sum Beneficiary Designation form; CalPERS did not reference the Application to Modify Option and/or Life Option Beneficiary form, nor provide any information for designating a new beneficiary for Option 2 lifetime monthly benefits. In addition, CalPERS' August 14, 2014 letter failed to: address Grantland Johnson's request that Lee Turner Johnson be named as the beneficiary for all of his CalPERS retirement benefits; reference or respond to his Application to Modify Option and/or Life Option Beneficiary, which was received by CalPERS a week earlier, on August 7, 2014; or provide any further information relating to the modification of his Life Option Beneficiary or notify Grantland Johnson or Lee Turner Johnson that the process was in any way incomplete. Grantland Johnson died five days later on August 19, 2015;

• CalPERS' letter to Lee Turner Johnson on September 9, 2014 requesting that she return an application claiming death benefits, without referencing Grantland Johnson's prior Application to Modify Option and/or Life Option Beneficiary or notifying her that the process was in any way incomplete;

• The telephone call between CalPERS and Lee Turner Johnson in or around December 2014 during which CalPERS represented that it was awaiting a copy of the final judgment on property in the marital settlement between Grantland Johnson and his former wife before completing the process related to the designation of lump sum benefits and other benefits made by Grantland Johnson prior to his death;

• Lee Turner Johnson's letter to CalPERS on January 12, 2015 which in part referenced and enclosed a copy of the December 31, 2014 final judgment on property in the marital settlement between Grantland Johnson and his former wife and in which Lee Turner Johnson stated that she was awaiting decision or further instruction on retirement benefits requested prior to Grantland Johnson's death. Lee Turner Johnson also enclosed a copy of Grantland Johnson's will, an additional copy of her marriage certificate relating to her marriage to Grantland Johnson, and a copy of Grantland Johnson's death certificate;

• . CalPERS did not provide notice to Lee Turner Johnson that she would be removed from Grantland Johnson's medical/dental plans or that such benefits were contingent upon her designation as a beneficiary for Grantland Johnson's Option 2 lifetime monthly benefits; and


Ms. Preet Kaur CALIFORNIA PUBLIC EMPLOYEES' RETIREMENT SYSTEM

September 25, 2015 Page 3

• Lee Turner Johnson's letter to CalPERS on February 14, 2015 which in part protests CalPERS' decision to remove her from Grantland Johnson's medical/dental plans, reasserts Grantland Johnson's request that lump sum and Option 2 lifetime monthly benefits be provided to Lee Turner Johnson as his designated beneficiary and consistent with the court's final judgment on property in the marital settlement between Grantland Johnson and his former wife, and references CalPERS' telephonic assurances to her that Grantland Johnson's "wishes would be honored even if after his death."

In addition, pursuant to Government Code section 11507 .6, please provide the following supplemental information and documents:

4. A copy of the CalPERS publication "Changing Your Beneficiary or Monthly Benefit after Retirement" (PUB-98) that was available or published on May 2014; and

5. Documents, notes or reports including but not limited to Customer Touch Point ("CTP") reports relating to telephonic communications between CalPERS and Lee Turner Johnson. 1

This is a continuing discovery request. If you deem any request to call for privileged information or documents or electronically stored infonnation, and assert such privilege to avoid divulging such information or producing such documents or electronically stored information, please provide a privilege log containing information sufficient so that the administrative law judge or a court may rule on the claim of privilege. In addition, if a responsive document once existed and has subsequently been lost, destroyed, or is otherwise missing, please provide sufficient information to identify the document and state the details concerning its loss or destruction.

Sincerely,

KERSHAW, CUTTER & RA TINOFF LLP

IAN J. BARLOW

IJB/la

1 The numbering for the discovery requests contained herein are continued from previously submitted Request Nos. 1-4.


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April 1, 2015

California Public Employees Retirement System Benefits Services Division and Members of the Cal Pers Board of Directors P.O. Box 1652 Sacramento, CA 95812-1652

NOTICE OF APPEAL

Re: Dr. Lee Turner Johnson - Reference Number

Dear Benefits Division and Members of the Board:

The following letter constitutes a notice of appeal on behalf of Dr. Lee Turner Johnson to the Division's March 4, 2015 decision denying Ms. Turner Jolmson's application to recalculate_h~r late husband Grantland Johnson'~-~tion 2 benefit. As a result of the decision, Ms. Turner Johnson was incorrectiy denied life time health and dental benefits.

• •• ··-·----~---· •'--~--• .. _L _____ ________

Ms. Turner Johnson's appeal is based on the PERS Benefits Division's overly restrictive reading of the relevant statutes, and basic principles of equity and fairness. The late Grantland Johnson clearly intended before his death to change his optional settlement beneficiary option to Ms. Turner Johnson. Only his untimely death prevented him from finishing the process. The relevant statutes address only the requirements for a living retiree to complete the process. The appeal should be granted.

The key facts are as follows:

I) Mr. Johnson had previously been married to Charlot Bolton. Their divorce was finalized on November 9, 2013. On November 15, 2013, Mr. Johnson married Lee Anne Turner Johnson.

2) On December 12, 2013, Mr. Johnson wrote CALPERS requesting that his wife Lee Anne Turner Johnson be added to his retiree health plan.

3) On June 23, 2014, Mr. Johnson wrote CALPERS requesting that Lee Turner Johnson 'be named as the beneficiary with my CALPERS retirement and all death benefits (previously named for Charlot Bolton and Patrice Bolton Johnson.)' · -- ·

4) On August 5, 2014, Mr. Johnson signed CALPERS 'Applicatiqn to Modify Option and or Life Option Beneficiary' to designate Lee Turner Johnson as his new beneficiary. He further signed the 'Post Retirement Lump Sum Beneficiary De~i~ation' on the same form on the same day.

- - - - ---

' RESPONDENT'S I EXHIBIT

I 11

Attachment G Respondent's Exhibit B Page 1 of 5

5) On August 14, 2014, CALPERS wrote Mr. Johnson confinning acceptance of Ms. Turner Johnson as Mr. Johnson's beneficiary.

6) On August 19, 2014, Mr. Johnson died.

7) On September 9~ 2014, CALPERS wrote Ms. Turner Johnson requesting that she retun:i the CALPERS application claiming death bene~ts.

8) On January 12, 2015, Ms Turner Johnson sent CALPERS a copy of the final judgment on property in the marital settlement between Grantland Johnson and Charlot Bolton. The settlement endorsed by the court on December 31, 2014 provided that all interests in Mr. Johnson's pension be 'Confirmed to Husband' (Mr. Johnson) ···

~ • • -- - • .# - ' - ... - .. _., -----... _,_ ...

9) On February 14, 2015, Ms. Turner Johnson wrote CALPERS in part to protest CALPERS decision to remove her _fr()m ~~:1.Q~SQ!l's medic.ajld~ntal plans.

10) On February 17, 2015, CALPERS wrote Ms. Turner Johnson informing her that they were remo~i11:g_ ~_9_c~.rl9_~_~plton's community property claim against Mr. Johnson's pension and referring the remainder of Ms.Turner JOhllson's cTaunto its Death Benefits Unit.

11) On March 4, 2015, CALPERS Benefit Services Division wrote Ms. Turner Johnson by certified mail denying Mr. Johnson's request to recalculate his option 2 benefit on behalf of Ms. Turner Johnson. The division denied the request under Government Code section 21462 because '(b)oth the member an~ th_~p_e\\".. beneficiruy_ must be alive-ol}J~e-~ff~ctfy_e_~ate. Unfortunately, Mr. Johnson passed away before he was awarded full interest in his retirement benefits and before a recalculation election document could be provided to him.'

ARGUMENT

I. Mr. Johnson Expressed Clear Intent Before His Death to Change His Optional Settlement Beneficiary To Ms. Turner Johnson

There is no factual dispute that on numerous occasions before his death, Mr. Johnson clearly expressed his intent that Ms. Turner Johnson become his sole option 2 beneficiary. His December 12, 2013 letter to PERS asked that Ms. Turner Johnson, his new wife, be added to his retiree health plan. On August 5, 2014, he signed the formal CAL PERS application to do exactly what Ms. Turner Johnson now seeks, to become Mr. Johnson's sole optional settlement beneficiary. His intent is not in dispute.

2. Mr. Johnson Substantially Complied with Government Code Section 21462 Before He Died

California courts have long held that substantial compliance with a government requirement should uphold a claim for relief.


"·

wsubstantial compliance, as the phrase is used in the decisions, means actual compliance in respect to the substance essential to every reasonable objective of the statute.' Where there is compliance as to all matters of substance technical deviations are not to be given the stature of noncompliance. Substance prevails over form. When the plaintiff embarks [on a course of substantial compliance]~ every reasonable objective of [the statute at issue] has been satisfied.'~ (Emphasis added.)

Cal-Air Conditioning, Inc. v. Auburn Union Sch. Dist., 21 Cal. App. 4th 655, 668 (1993) (quoting Southern Pac. Tranjportation Co. v. State Bd of Equalization, 175 Cal.App.3d 438, 442 (1985)); see also Freeman v. Vista de Santa Barbara Associates LP, 207 Cal. App. 4th 791, 793 (2012) ("Substantial compliance with a statute is dependent on the meaning and purpose of the statute."); Costa v. Superior Court, 37 Cal. 4th 986, 1017 n.24 (2006) ('•each objective or purpose of a statute must be achieved in order to satisfy the substantial compliance standard").

The only reason Mr. Johnson did not complete the process as described in the denial letter was his untimely death on August 19, 2014. It is obvious that he would have followed through had he survived longer.

Section 21462 (a) (1) does condition a retiree changing his beneficiary from a divorced spouse to a new spouse in part upon a 'judgment' which 'awards the total interest in the retirement system to the retired member.' There is nothing in subsection (a) which states a time line for submission to CALPERS of such a judgment.

Section 21462 (b) provides the relevant time lines. It requires that the election to change beneficiaries be made 'within 12 months of the entry of the judgment dividing the community property of the parties.' Since the community property decision was filed and endorsed by the court on December 31, 2014, nearly four and one half months after Mr. Johnson's death, it fell to Ms. Turner Johnson to submit the court decision to CALPERS. She did so on January 12, 2015 and again on February 11, 2015, well within section 21462's 12 month submission deadline. Mr. Johnson's actions clearly constitute substantial compliance with CALPERS' requirements.

3. The Government Code Sections Do Not Address This Unique Situation For It Was Impossible For the Retiree to Comply

The courts have also long held that where it is impossible for a party to comply with a contract, he should not be held responsible for full compliance.

[U]nder general contract principles, appellant's obligation to perform under the contract would be discharged due to impossibility, impracticability and frustration of purpose. Performance under a contract is excused "[w]here~ after a contract is made, a party's performance is made impracticable without his fault by the occurrence of an event the nonoccurrence of which was a basic assumption on which the contract was made, his duty to render that performance is discharged, unless the language or the circumstances indicate the contrary."


In re Marriage of Benjamins, 26 Cal. App. 4th 423, 432 n.3 (1994) (quoting Rest. 2d Contracts,§ 261); see also Mineral Park Land Co. v. Howard, 172 Cal. 289, 291 (1916) (recognizing that impossibility, but not mere difficulty, excuses a party's performance under a contract); Cazares v. Saenz, 208 Cal. App. 3d 279, 285 (1989) ("[P]erformance is excused when [a] party dies or becomes otherwise incapable of performing." (citing Rest. 2_d Contracts,§§ 261, 262)). The Restatement of Contracts, section 262, cited in Cazares, provides: ""If the existence of a particular person is necessary for the performance of a duty, his death or such incapacity as makes performance impracticable is an event the non-occurrence of which was a basic assumption on which the contract was made." Rest. 2d Contracts, § 262.

The doctrine of impossibility applies foursquare in this situation. CALPERS Benefits Division bases its adverse ruling against Ms. Turner Johnson on the necessary fact that she submitted the court document clarifying the community property issues instead of Mr. Johnson. Despite his clear intentions, Mr. Johnson could not physically comply with the statute because he died before he could fully comply. CALPERS Benefits Division said specifically in its denial letter, 'Both the member and the new beneficiary must be alive on the effective date'.

There is nothing in the statute which explicitly states the above. It is undoubtedly true that in most instances, if the retiree if able, he must follow through with the entire process including section 21462 (d)'s requirement that '(a)n optional settlement shall be selected by a member in writing filed by the member with the board.'

The statute however does not address the current unique situation. If a member is entitled to redistribute his entire retirement per a divorce settlement, clearly declares his intent to distribute that retirement to his new spouse, and then dies before he makes the final election, should the new spouse be denied the benefit of his clear intent? Such a result would be patently unfair and contrary to usual statutory construction.

4. Given That The Statute Does Not Address this Unique Situation~ CALPERS Should Adopt Its Own Unequivocal Intent I Substantial Compliance Rule

The Benefits Division's decision is neither fair nor necessary under the law. No one will be hurt if CALPERS grants Mr. Johnson's wishes. His ex-wife would not be prejudiced as their divorce decree granted all the retirement benefits to Mr. Johnson.

There would be no damaging precedent to the PERS system if it granted Mr. Johnson's wishes. CALPERS obligations are clear when dealing with a living retiree. A living retiree must follow Section 21462 in its entirety.

Since there is no statute which addresses the status of an election to change beneficiaries when the retiree dies in the middle of the process, CALPERS should adopt a quasi judicial rule for similar situations.

The rule should approximate the following; 'If the retiree dies after commencing but before completing an optional settlement beneficiary election, the intended beneficiary of a deceased


..... · . .. .

retiree must prove by clear and convincing evidence (or some similar high standard) that the retiree unequivocally intended to elect that new beneficiary prior to his/her death.' If the new beneficiary meets that standard, he/she should be entitled to all the deceased retiree's optional benefits.

In this case~ Mr. Johnson's actions would clearly meet the above test. CALPERS should grant Ms. Turner Johnson's appeal.

Respectfully submitted,

Lee Turner Johnson


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who proved to me on '!he basis of satisfactory evidence to be the person(s) whose name(s) is/am subscribed to 1he within instrume~t and acknowledged to me that he/she/they executed the same Jn hlslherllf1elr authorized capaclty(les), and that by hishlerlthelr signature(s) on the Instrument the person(s), or the entity upon behalf of which the person(s) acted, QXBCuled the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of Caltfornia that the foregoing peragraph Is true and correct.

WITNESS my hand and official seal.

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FEB-11 - 2015 02:55PM From: 17077596053 ID:CALPERS

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i RESPONDENT'S ~ EXHIBIT

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Attachment G Respondent's Exhibit C Page 1 of 2

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3/2/2012

-------- .. . --·· Final WDI and Testament of Grantland Lee Johnson

rn the event of my passlns, I name and authorize Dr. Lee Turner- Muecke, my flano§ and medlcal authority as Power of ~rney and Executor of my will to complete the executlan and dasure of my estate, and the estate of my grandmother, Irene Jefferson with advice and assistance of Herb Am:lersan of oaldand, CA.

The fallowing are my directions as to the eacution of '"l personal affects and assets:

1. Camnlete the sale af the house (Irene Jefferson)at

1 whose estate I am executor and power of attDmey far. (Real Estate broker Andre Tenthorey of Keller Wllllams)

2. Take the proceeds of this sale to

a. a) reimburse mv estate for all repairs to 1he house In the amount of $22,000), and tD pay off my IRS and Franchise Tax Board taxes with this monay.

b. To take the amount owed by me to Dr. lee Turner-Muecke for apenses Incurred related to my pandmothar's funeral o" December Z, 2012 and to help rne prepare the house for the market. (lnvak:es attached)

c. To take the remain Ins balance after the sale Is erased wl1h paymenu to Sacramento County and City of sacramento In the dosure, commission fees, closing feas and any taxes appUable , to disperse the remaining funds, as per the wlll of my grandmother, to those descrlbad In the will. The amount balonglng to m11 gues to pay for my burial expenses fll'lt and the remainder to my dau&hter, Patrice Bolton Johnson, along with any

baoks, m's, DVD's and personal affects she may want. d. Any remaining personal effects belong to Dr. Tumar-Muedce to use ar

disperse as she wishes. e. Dr. Turner-Muecke has access to my accounts and wlll settte any amounts

owing to my Grandmother's Joint account and Is full Powar of Attorney far and Exacutar for my estate and that af my grandmother's.

Signed~~~ Date:~~ .2 :Z o( .a<. I

Grantland Lee Johnson

FEB-11-2015 02:55PM From: 17077596053 ID:CALPERS Page:006 R=95~

Attachment G Respondent's Exhibit C Page 2 of 2

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2013 DEC 16 1\1=1 9 38 December 12, 2013

Cal PCltS ·PO Box 942715 Sac1amento. CA 94229 2715

To Whom t May Concern

Plea~e add I ~e Anne Turner Johnson, my new wife to my Health Plan \'\11th CalPEl~S As of November 15, 2013, we are legally marned I h~ve mduded a copy of the Marriage Cert1f1cntc, Lee's Socactf Security card and her birth certrf1cate Thank you

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Plensc send conf1rmDt1on of her plan coverage to us at

G1 dntland Lee John~on cind Lee A Turner lohnM>n

I thank you for your prompt dttent1on to rlns matte!'

Grantland L Johnson

' RESPONDENT'S i EXHIBIT ~ 'b)

L-------------------------------------.------------~----~----1 .. D. ______ •

Attachment G Respondent's Exhibit D Page 1 of 1

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l want my wife Lee Anne Turner Johnson, to be named as the benef1c1ary with my Cal PERS retirement and all death benefits (previously named for Charlot Bolton and Patrice Bolton Johnson) As of November 15, 2013, we were legally married A court Judgment or manta! agreement w1I\ soon be filed and sent to you, finahzmg all property with my former wife, Charlot Bolton Upon receipt of this final settlement agreement, please 1mmed1ately change all of my retirement benefit and all death benefit to mywtfe, Dr Lee Turner johnson Once completed, please send conf1rmat1on of this change to us at

Grantland Lee lohnson and Lee A Turner !ohnson

I thank you for your prompt attention to this matter

Sincerely,

~~ Grantland L Joh~'1

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i RESPONDENT'S ; EXHIBIT

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Attachment G Respondent's Exhibit E Page 1 of 1

.~CalPERS

July 25, 2014

Grantland L. Johnson

Dear Grantland L. Johnson:

P.O. Box 942715 Sacramento, CA 94229-2715 888 CalPERS (or 888-22fr7377) I Fax: (800) 959-6545 www.calpers.ca.gov

California Public Employees' Retirement System

CalPERS ID:

The Beneficiary Designation Form, which you recently submitted, cannot be processed because of the following reasons(s):

· An incorrect or invalid form was submitted. Please complete the enclosed form and re-submit.

You must complete a new form, which is provided. Please review the "Information and Instructions" sheet before completing the new form and make a copy of the form prior to mailing.

If you have any questions, please visit our Web site www.calpers.ca.gov, or you may contact us toll free at 888 CalPERS (or 888-225-7377).

You may submit a new beneficiary designation at any time by logging into my!CalPERS

my!CalPERS 0589 ~ RESPONDENT'S ~ EXHIBIT

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Page 1 of 1

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Attachment G Respondent's Exhibit F Page 1 of 1

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----· - ·--Cah1om1a Public Employees Retirement System

Post Retirement Lump Sum Benef1c1ary Designation .#l!.!.111 Member lnformat1on

Please include your r1rs1 name middle Grantland L Johnson

1m11al and lasl Members Full Name SSN or, Cal PERS ID Telephone Number Birth Date name

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the lull nan1e of your

benshetaries relat1onsh1p

Social Secunty number or

CalPERS ID and lhe complete

address

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allach add111onal sheels provided

you indicate whether you are

deSlgnating p11mary or secondary

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Check~t11t r Box I or BoA 2 If you che<:k Bo" 2 also 1nd1cate benefit type hereby designate the followmg person(s) who suMve me share and share alike rl no

1 percenlags (%) 1s given as BENEFICIARIES lor any lump sum death benehts payable under tl\e Public Employees Reurement Law 1n the event of my death

ttJl?o!- Or

2 D I hereby designate separate benehcianes tor the various lump sum benehts that may be

payable This designauon 1s for

0 Rsured Death Beneht 0 Oplion 1 Balance

0 Temporary Annuity Balance 0 Option 4 Oplion 1 Balance

Beneficiary Des1gnat1on t understand that 11 I am mamed or in a reg1Slered domestic partnership but do not name my spouse or rt191stered dom~t1c partner as benehc1ary they may be ent1Uad to a community property share of the balanet1 of contnbutJOns (Dphon 1) 01 Temporary Annuity Balance The community property share wdl be based on one hell ol the con111but1ons or one hall ol lhe service credit earned dunng the marnagel registered domesuc partnership II the marriage or pa11nersh1p occuned alter my re11remen1 date then my spouse or registered dome!lliC partner 1s. not enuHed to a community property mteres.t II a community property mteres1 applies my designated benel1aary1ies) w1!1 receive the portron cl my lump sum Option 1 or Temporary Annuity Balance lhat 1s not payable to my spouse or registered domestic partner a!; their community property share

Primary Benefrctanes

D v L e.t.-YLL~~Q"Uh"1-~ Name ot Pnmary Benehciary /]

ii I ( [e., (O?) /{) Rela11onshG'to lhe Member Percenlage o1 •ho ~•mef11

- "'>"'T - I Address (Number Street City State and Zip Code)

Name ol Pnmary Benehc1ary

Birth Date

Social Secu11ty Number or CalPERS ID

9a,611.vttulo161-' qne~ I

B1nh Date

Relat1onsh1p to the Member Percentage ol the Benefit SoCtal Secunty Number or CalPERS ID

Addre!ls 1Number Street City State and Zip Code)

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Page 1 ot 4

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Attachment G Respondent's Exhibit G Page 1 of 4

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Gmntland L Jolim;on 3o,:ial S~Ulll )' Numt1<;1 01° CatPE ns ID

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11 a pt<rcemage (%) 1s Primary Benef1c1arres - Continued entered makt • sure the total equals 100%

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bem1hcrar10s You mu;.t sign d.'\te and wnt~

Nam,1 ol Pnm:iry Benel1c1ary 91nh Dale

Rela11onsh1p Jo the Member PcrcelliClge 01 ihi! 3cnehl So::1al St::curll y NumoEH or CnlPERS ID

/lddrcs:; (Number S1rcc1 C11y S1a1tJ and Zip Code:)

In lhil ovon! I survive tho porscn($1 named ;is orimary bilnol1::1ary I hereby de!'1gna1e the loll~wing porson1s) who ~.urvive me as 6::N::FICIAR1:: s 11 no pmcemagc• (%i 1s given oene1r1:; will be paid s hare end share alike

Secondary Benef1 c1arres

· your Soc1;.il Name ol Secondary Brmtll1c1ary 3rnh Date S-:cur11y number

or Cal?::Rs ID al lhie lop o f each

addnional Rela11onsh1p to the Member Percentngo 01 the Beneln Social Secun1y Number or CatPERS ID

shei;,1

Adarcss tNumo ?r S1ree1 C11y S1a1e and Zip Code)

Name cl Secondary Bene11c1ary Binh DillP.

Rolal1onsh1p :o lh£: Member P&rcent:igc of the 3 ;:nc111 Social Securrty Numoer 0 1 CalP:=Rs ID

Address (Number Street C11y Stale and Zrp Code)

mylCal?ERS 0773

Page 2 of 4


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Put your nnmc nnd Socml Sccurlly number

or CalPERS ID al I he top ol every page

Gra11rt;md L J ohnson

~quired S1gna1ure(s)

Provide Jhe di!Jc you Member's Acknowledgement :;1;;ncd Jhe form Sh:iufd f survive: ;ill ol Jhe pcr~on:; numed I under~tand that Jhc benef i t~ pilyahle uoor. rny death wil l b,:,

paid lo my s:alutory oen<::lic1a11!!~ o; Jo 3uch otlh?r benehc1ary or bone11c1anf!; that l may h ereattor d<!s1grwtc 1n wr!llng lo Cal?::RS all 1r1 uccord;ince v1111l applrcablo prov1s1on::. ol J.iw

Ii you are m;m1(;d or 1n a reg1:;1cred doniest;c pannersh1;:i and your spouse or rog1:;1ered

domesuc p:inner does nol s19n Jh1s form you

By lt11s benelic1.:iry d a:;:gnauon I hereby revoke .:my pr!!v1ou:, des1gna11on I il;ive l1Jad I undar~1and tt~at my marriage or dorne:>t1c pannersh1p lrnal d1sso1ut1on or .:mnulmenl of my mamagi< or the 1er1nir.auon 01 my domesilc ::>iir1ncrsh1p er Jhe b1nh or aoo;:it1cn of a cntl:i sub>~:;u~nt Jo 111e date 1n1s !err.: 1:; file:: wlih Cal?!: RS will autom'lli~ally •:010 Jl us dQ~1gn311on

I undersrnnd Iha! a de~.1gnat1on tiled atJor lh? m111:it1on o f d1ssolu11on o r annulmenl ot mamage or domestic p.:innersh1p or leg<Jl Jerm1na11on of dorne'-trc oanner'.'h1p will not be 1evo'-ed wi1on lh<: leg~ I

proce::::; 1s f1r1<1h:ed /

Are you leg3ll;• m;ir r1e:J 01 h<Jvc a rc91~1ered dom&:;11: pannw? ~ Yes O No

II yes your spousc or reg1:;tc1ed domestic parJn:?1 musJ ;1gn 1111:; form II no please: 1ndrcatt•

mu:;J compi()l (: and D N()Vilr Marriedl Nfover rn Reg1,1ercd Dom,;::;uc PanMr:; t11p 0 D1vo1cedl Annulled n W1::owed subm111ha

Juslificollon for IMPORTANT You mu:.1 complcit:: the Jus11hca11on 101 Ab:.cn::e of Spou:;e s or iieg1s1ered D::me:;uc AbsQnce of Spouse 5 Parincr ~ Signature (n1yJCalPERS 0175! 11 you ;im married or ha\'e a reg1s!t; rc:d cfo111estrc partner::;nip but

or Registered xour !l OU!le ~r ! l' . 15Jered dome:;J1c panner 1$ unable JO ; 1gn be low

Dome sue Portner s ( /) "'-f- ,., /\. /'\ /,, /, /; Signature • ._...~"---0'~, v A::; ~ V~/.:...OT (], 5 -

1niyJCaJC'c RS 0/:'5.1 · I form wllh your Mumbt<r:; S1gn;:;1uri: 1 D~ l t! (mmldtliyyyy)

oes1gna11on form

Bo1ore subm1mr19 yow compf<:ted !orm be

:;ur\:: to make n copy t:i \\eP.p with your

rmportanl re111c,rnenl 1nlorma11011

Spouse s /Reg1stered Dome stic Partners Acknowledgement By s1gn1n9 tt11:, oe1ml1c1:.iry des1gna11on fcrni I .-i ::~nowle::ige 1h2t I ;im awaro ol Jhc desrgn.;;11on niade by my spouse or rcq1s1ered come51IC :Jilnner I a!so hereby st.:i!r: 11".aJ i am Jh~ curron: Sf:O:Jse o: re91:;1ered dome:;t1 panner

Spouse siR!!(]r' ered Domes11c Pm Iner {! ~nalurP Date (mm1cJd-'yyyy1

/I (~ 1lµ Date o f Marriage or Reg1s1ered Pannersh1p i.mm1dd1yyyy)

(

111@@11·1 If Ca!PEriS Benefi t Services D 1v1s1on • Po So· 9.;271 ; Saa.1merno CA 9.::29 27 11

my!CalPERS 0773

Page J ol 4 I mi m I l1l 1ii1i1 illi1i~ 11111111111\i l 111 ii I [[ [ II


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M ... -0 ..._ 00 0 ..._

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L myjCalPERS 0773

Information and Instructions

Instructions T he death tx•nel1tf. p;1.o le yCJur tuneh.;i.i1y ·:h:pe:no on the •t:t1rcm.;-n1 option ycu SC•JCCleo w hon you i eur'::d anc the ocr.el11s con11ac1ed by youi to1mer employer Pion:;~ ordc1 or downlo :id What Yo11 No.::d to Know About C11:mgmg \'our Benal1c1af)· or MiJnr/11.1• 81met11 .:ifr.::r tl:Jlrremenr for a •.Jt-scrip:10 11 01 tht: bcn <;;1Jt$ The r'~S I Rct1·~ment Luino $um Bt:r1~11;1a 1y (les19na11on lo rm 1:; UStlO to d ":s1gn?.l!:c ?.

ben;,f1c 1My11~~) 101 your iuin;i sum bun~ilt~ only

A Th.; !allowing rs n !isl 01 ;ill 111:: tunio sum bcnr.-111·; th:n cou!CJ be pwd I R,,11r~d Ol!;tlh 8 0111:111 2 Op11on i 8 '1ltir.:(-3 Tempi:1rary /'ir.nuity eal;rnct: 4 Op11on .i C!o11cn '2W or '.1W a:ici Op11on 1 Cumb>ned Bal<snc!!

Any lum:') sum de~th h~neh i :; will hi:- pu:-: 10 your df':s ; gn:il~~~ oen-;ncmry How.:.: ·1er 11 no vnh~ d-?r.1gna11on 1~ 1r. on~ct at tt:i:i um-? ot you1 oeo1h your lumo SJm durtth b~n·jl :t s n1r:: cu1d to your statvlcry oenel1c1ary (l t"ii! 01ce: 1;; de1e:1r.111<:d by 1.w,·i

6 Any ot tn;; lcllow1ng events au1orna11cull1• rr,vok;: ;m O:•lcH•ll·J o~ne:ltcm 1 y dcs11;mut1or. 1 M;imag,; - ·- ----·-- ..

2 Reg1~1a1 ed r1orn~SI•~ p~r~n'.:r.;h1p 3 D1~ .;otu 11on or ;rnnulrn~n l of m;uu~ge c: 11,:rrnir:au i:•n of .=t rog1$Wred c ome:;t1c p2rt:,crsr.1p lriJ! 1:; 111111<1~0 1 0 lh<:.d,,s19n.;11on r" l1IP.d

J 8111 11 or <idop11c·11 o1 ,, cruld

II yuur banehc:iory o~s1gn:i11r; r. 1s r~\'O~~c ~no the1t1

1 ~. no d~s1gr,a1 1on m t:Htcl at tno 11me c: you: !"Jt:alh br:ncf.1s will o~ n~1d to yo111 <=-ialulO"r' t 1u ri~l1r;1.~1r;· H·YN~:vHr you t:tln 1'=":::H::-19natt- you ! previous b~·ne11 c:ary 01 n;i:ne a m:w L•,ne:11~1Jry by c:orr.pl.;:1ng this 1orr.1

C It you .:11C1l~:;pl l1·1nn111~tl 01 "' ~ 1eg1~tcrcd do1ni;.~,11c oa11ncrsh1p ;md you d,:.~1gn;11,,. !'Corl"C:CJn·J o l h~r than yt1ur !'-p~u;c- 0r re91s1.,red ~c:n.,;suc partn~ r to rec·::11•e you' Op~·'.1" 1 b:t l?.n~~ 111cy wuld tJ~ .:nrnl2c! 10 tilcm c~mmumly orore-ny 1ntu: t:1s t in th1~ beni:lit Tht.?1r community pro:l~rty mter<:Si 1:; 50 rn:rc0ni ot lhe t·on~!11 1or lh-:: por100 C·l~11PER5 ~e.!Y'~~r_v~~1ch yti~ ~~rn-::o ~YOU! CIJ!'r•]OI f·R,O IJSC Oi 11 1 a rcg1:;1ered o.Jomu:;t1c p~!'1nl! r sl11p t! you m;irnvd or established ,l rcg1stared clorn~!; tic p:~r1nersh 1p attvr r~hrt:H~'cril ;-nur !ipUu~~ or registered dom·.::su: pu11nt•1 do~~ not r.:w•: a c:,m:nurnty propC!rty 1mcr·:s! 1n you1 d.::;,111 t;<!n"'rw.

D In S~i::11 :.i11 I H!Jnl!"lb<::t 1f!..£g=:i!.!Y_?.!.' !llJDt(.P,;rsonm rn101mu11on roque!"ted a ! thil too ol thc, lo rm To prol<::C'. you a11d your oeni:11c1~1y frcrn a po~.;1ble tt:9al challP.~g~ o! you1 or;s1gnat1ong we .; anno: ;;cc.:pt a -x" iorm with any co11~..:11ons n1 li1t!sure mnr~~ Alsv r\'rn•1mo~r to cho:- ch e:ther Bo i. 1 o r BOA. 2 Ch-2c.:k Uor / 'Y

i 1f your d-;?$:gnJ:iCm ?.Pt-~ to all (lpphco~~·.: lump S'Ji.l r.H:a:\1 ::a:ne!ns Ch~c:... BOA 2 11 you w::rn1 lO C~s1y11a\~ a r11trr.r.-n; b;,n~1 1r.: ~ ry i01 t1act1 lurrp sum .jei!th ;ien•:•hl p:<V?.tl~ Y~u ' pnr.i:iry ll~n.,11c.a:ies m il 1.::ce1ve ;in eaual p:>rcenl ol !l•P. b•,nuf11 1.nl~ss you 111u1ca;e c1Mrw1~e

E Ir. Se..;110n 2 ti you wanl ~o namt: mU1'2- thnn t'1r8t: p11m::u y be net1c1r1r1e::. 0 1 r:"!O r•:• thn:i t:·:o sccond:-try b.,nr! trc1ari<:s 101 one o: u!I o: ;h;,.> tum,. sum d-.;ith b.::n·:ihtg vcu mav att;.ch ;idd111 on;il sr e·~1 ::: orov1c~r. you 1r.a:c~l!: wheth.;·' you a:~ o.::s:gi:at1ng ;:irimary or se-:ondary benehc1arie~ You m1,1_sl sign oate ;ino writ.;, your Social Se:u11ty number 01 CalP:OFlS ID at tne IOP ol °"acn a:id111oni1! ~hec:

F In Se::uon 3 yc·J ro_us.t sign fh~ A1emtu.'t ~; Ac/..nowli:.'<19t:'mt1nr and ycur cL:rrent spous~ or reg1~te red

dome<.11c par.n;,r m4sJ ;itso ~19n the Spous<J ,; 01 Reg10;wrr:xl .r:>om,>;:11.:: Pammi s 1i.::lmoll'l;;d9i:'m!!r.I tc <1Cf.nowled9e th~ .;c11on you ult- 1a•.inr- It y~u ilr~ no11egally m;11ri.::: 0 1 rn ;i ri-:t11s1c red uorn~st 1c

p;irtnt1:sh•P you shcu~d cnecf; 1ne bo' in me MC:r.'lbe' s AcKnowllldgom~nl s~chon staling 1h;i; you a r ~ not n1;,111ed or 1n ~ tlnrl"t?SllC pmln~rr-nrp amt mark th& co11 e::1 ;ioptic;it.10- ~.1tua11on II you <ire rn;1111,;lj or 1n il •tJ9 1~tcuJd d 'Jmus11c p'11111.;,sl11p Hrd your s;iousr, OJ 1t::g1r.t€r.:i:I doin<?:;uc ;:mrtner does nc; sign ; ~1= lo1m you mus t corr:ph?t~ :ln~ sutml1t :he Jus:111::.~11on for ADs1..-.ncr: al Spou.'1t! s n1 F?eg1:=t:!rf:!i:1 Oomesu: Par:n1~r s S1ynJJura !orm with your oes1!Jr.ci t1c:n term

Information Practices Statement

lho 1nform:i1ton Pn1c11.: e:. A<:I o l I ~1i7 and the ~"c.i r~ I Pr1vt!Cy Ac; r!!qu11 0 lhe C:i!i:orma Put.he Emp!oy"e ' Re111emeni Sy:;1ern ;o c1ov1~b thf! !CJllow1.1u 1nt0rmJ11on 10 1nd1v1dua1s who a1e asked 10 s:ip;:-ly 1r.1orrnil!IO'I Th,,. mlorma11e>n ,,.,quc"K-d 1$ coll~r.tod pursu:int 10 !he Government Coae Secucins 120(1(10 el seQ; and will be used for ndm1n:s1ra11oci ol th£• Bon rd s du11,;,s 1ir.rJe:r 1he Rel11<?mer.t Law the Soc1;.I S.;cun1y l\c1 and 1nr; Public Em:lloyee$ Mi;d:ctll ,1nd Hos;11i;:ll Care/,~-:, ~s. th~ cn~.e mtJy be ~ .:-u:w c ta su:Jply fill ct t :-i~ re·:t•J2 s1c: 1nfcirrr.a110:1 may rcsul11r. tn:: Sy,;1;,:11 being unab!;.; le o~rlorm its luncllor.: 1°'gard1r1g your sw1u~ Poruons o: 11115 mlorm?.tion may be !lan~lerred 10 state :md pub:1c ag~ncy employers Ca11101rna Stal"' Auorney G'o'nmal OH1r.e of th" Stal•: Controll1:1 C:thlom1a T<-0:h11ol::igy Agency Publ:c s~rc11 S Commvn1c<i t1011f. D""~1on F1 cind11!'-t? Tax Bo:.rd 1n1crr-~ I Re,·~nv<; Si1IYI'.:~ W.:rk!irs Como.:ns;i11on Appi:.al.; B ca'<l Stale Compen$<lll0r. lnsL.irn.nce '-\:~d County D1str~c1 Atlorn:?)'S S:>oi1I Sccur10· Adm1n!~t~n110n t>enei1c1ow~s ot di:?cei::st:d ;n~mbo~~ phys1.;;;m~ 1.--ist.:r~ncD c;1111~1;.. ~nd 'lCH :ou~ vt-n~or s w lh? pr~p:11~ rn1crof.chr;.:m1cro1tlm for C;i!PERS [•1:;cl~·suri: ;o these p a,11Es •~don.: in st11::t ~r.corcJanct w11n ·~ri!lr. I Sl:\llJIO::S reg:•rc1rng cc:nl1dr.:n11:i l1ty

I ·rou tt-=ivc• th~ r ? 111 :o r":' 't'ie\·,· yot.. r rn:~mn1.::1Shtp h1·:!5 mr:HHr1111.;·:l oy t''H:: C.':lhtorr.ii:i ;'ut:: l h~ i= .T.pl•:iye~s R:::tJrem-:-r.i Sy:-;lum For qJ£?~tWn!l con ;:t.~rn rnr; ycur r19hi5 under lht: ln:a1mntion PrclCl1c~s A::t of 1977 please C~niiiG I 1he lnlorm:J11on Cooro1r,a101 CalPERS P 0 Bor. 9~2/02 S'.\r.r:tm(!rllo Cl\ 8~229 27•)2

::'age 4 of 4


'° ., &ti &ft

'° CA

Ill Cll ., ., C'I ... "" c ..... co c ..... ., ... 0

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A CalPERS

•I'll.I·••

Application to Modify Option anrJor Lif c Option Beneficiary 888 calPERS (or 888-225 7377) m (&TI) 249 7442

_, ~~~~'~~~~~~~~-' ---~ Nim1I ol Parlcop;nJ (F11at Ramo Uld4le •m11JS Ull Hanzel ~ ~•ii • • -:u•1&, r 1aud • • •·• r.~ _

Quahfymg Events for Modification Please submit a copy You can change your benefit opttan or Ille option be112f 1ciary only rf one ol tlte foll0'.111to L \"nt& ttr.uu s Ind rt.ate Ille /

of appzvpnate legal event that appllas ,

document such as certified death cerbfate.

snamap c:erbflcate

certlfa:ate ot domestic partnership or the

endorsed hlad court order ,.1 -wrth tins applrcatmn

~ C'\J r

°' . u: 0w•1 :r.: '9) .: cc::: .. ::-'

.......

0 Death of current hfe optmn benehciary (submit a copy of the certlhed death c-ettdn.. ·11· 1

rtune 01 Botntltcaoir1 (ht:& naiao lo\iddrt 1111ua1 I.all Name)

0 Mamage csubmrt a copy of mamugs certificate)

t~me ol 5'J=se rF1n11 N:ime Middla lmb31 Lat N:1111e1

1111, I 1 I• ''""'"'''•lo :,.,ff)

L· d• 01 I """I'• c11111114dirm)

0 Establishment of domestic partnership (submit a copy of certlhcate of doml ')lie. P"l•Ulf r 111,11

1 t~n:re Gt D:lmostl( Partaer th1'$1 Nnmr Middle ln!Ual Usl "=nt) o .. ' II ~; ·~, I All• Odlnnl .. ,, ::; " .... I , Co ..!J _, :::>

(..)

g ~ce, annulment or legal separation from spouse or ex-spouse who r<: )Our ldr• CJJJhno I 11nl!hc11ry > q;c ..u ..::-u -"""

~ , .. f:'I

(sub copy of the endorsed filed court order)

rce , Af1# 0 annulment D legal separation If r , ., I• I 111: IStlh dol )m)

D Dissolution or nmnat1on of domestic partnershlP from domestic partm.r m c..< rl!'" • '•• J '' a • \llto 1s your lrfe option beneficiary (submrt a eopy of the endorsed filed court order> -----.# ___ ----

1>1 t 1 ll I I •all'' 'lllf}

•l'IUI·*• New Benehc1ary Information Complete new

benuftclary mfonnatron

and submd a copy af

th8tr lmth aJltlflCate

If you were required by court order at lbe bme of retirement to dBS1gnate your loi nn.r ~,sL."' • u r lsgally recogmzed domesbc partner as a Community Property Optscm 4 benefru.tr{ c.uru1 It ':.. ~ • • n ' ' ",

Do rmt complete Sectrons 2 and 3

.-f\ ~' _L~e_e. __ A~--'!~~u..-Y~~rrtV~VO'-=-hVJ;.;...:'>t?fl~---~-' N.11118 Cl New 8enatJC1lfJ CfUsl ll:H~ llld4Je lralu;J last H3nzeJ , r I t I • I I

or--h(b ' 2: nrrtC ~.~~~

:~bl~~~ ,(IA l~__j~,'?,·h-~~ .,_Ca_1,-_ _....__...__..._ _________ ...,S1-111e_.__,'-zap.......,_ •11t1 ·----

v7 lhr 10 'nl:I ... ,cmpage2

tt .....

POOR QTJALITY r.,....!"'°"'J!'° • T

,

Pe$01M0014 DMCf91t3) Page' Of3 ' RESPONDENT'S

i mBIT -------1 .

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!, /F

Attachment G Respondent's Exhibit H Page 1 of 3

Section j Option 4 Types We will provide Opbons 1 2 2W 3 and 3W If these cm nat meet vaur needs ,..

~ you can reques1 one of the lt1 in

approved Option 4 ID m

types shown tO ~

• ~

Yo_u must ~t revzew caf PEAS pubhcatum Retttemenl Opt on 4 b. 0 ~n 2W & Optm0 ' Comb111ed ~~,---:..~Tctim=t&J'Hretnirnrraiiiiliffii

ifspeClfrc P.erceptage to Rem·lSGtm y ~fj Ospec1r1c Dollar Amcun1 to 1,...,1!''ir1 .. , P91~iD ~

D Reduced Allowance for fixed Period of Time 6 U Reduce my Allowance bys----=-:'."""---- or ____ % U11ough the• nsl o• ------

oc11ar Amollllt Pcrc!llU3ge

ti\ If JOU wan1 your ... 0 Multapfe l.Jtellme Benefa:1ar1es ,.. baner1caanes to recmve 0 ...... an equal sham oi your a>

0 ...... benefits do not specify • ...

'At• I t •II , u ...... I .. L.lll'ERS ID

0 a cmDar 01 perwntaga N

ot the benefd

!Dunt Opia Gt11def IWlttl, •l•,I 1h1

'...xrtS o1ta , I 11a1h 1 11 CalPERS ID

!Or• OFllMle Genoer Aeiauonstup II) You l)t1lh1 I IC \IVSI I

Sl~tr ZIP I lllt1'

IWl'ta 1Fus1 ~me Utddld lnsbal Last Ulinel •• I I ~ .. , • ,. I • • 11f'ERS 10

!OM:!h OFemalll "l'ult 11 •I II •,I

Sl3fe '''"

0 Reduced Allowance Upan Death of Retiree or Beneficeary _, -----Rtoduc111111 Amcuns

PBISOIMD014 OW: (9113) Page2ol3


ID

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Put your name and Social Security number or CalPERS 10

afthe top of every r:age

• ifflftfflt. These opbons apply to

Ocbon 4 Court Onkrcd

Community Froperty only

Complete new beneficiary

mlormat1on and submit :i

cop:: or their t 111h certificate

•m1mm II your $fl0l!Se er domesbc

IJ<lrtner 1s your ehgtble

survivor you mus1 submit

a copy or your mamage

cernhcJte or cert1hcate of

domesti: partnersh;;i

• ffilffifl •

Option 4 Court-Ordered Community Property

0 Option 4/1 - To complete this oplton choice you mu::t also fill out th~ n!!•.'! L:cn·'liL1·1: ·: 1nf.r 111 11n 11 nclow

0 Option d/2V.' - io complete tms oplton ~ho1ce you must also hll ou: t:1~ 11~r: !::.rn. !11 · 1:-: 1 :· :-:: :1:.-.: .~:1 t::0low

C D;Jlion 4!3V.' - io complete th:s option choice, yo~ must atsc hll ou? th·. 11: . • : :.· . ... : i · .... , .. ,,, · ·" "-:·: ·,. l:r:low

.. ( .. . . 1 · .... •1. : ..... 1: , • . • .. :..tPrn~ 10

l~d:J t 1u::::11;i to 'l'uu

:.aores:;

Sl~lr 1.1, 1t : ·.

Survivor Continuance

I currently have an ehg1blc su:v1vor -.·1ho may oe cnlrtlco 10 the Survr:or ContmuJr!LL ~L ·a Ii

Cert1f1catlon of Part1c1pant

I umlerslancl \ha\ \his !mm 1s a reQue!:t icr an elac;t1on 1orm to rnon1ly m;1 o:in:r. 11 <'.I" :r: • : 1-. ·

bcnehcrary11esl I furiher understa:id th~ t my new op11on/bcneficr21y chun9:• '"1ll •::;1 ••· ,.1t•c· .. · 11· :• <1

the properly coaipleted elecuon form 1s subrr,rned to CalPERS I lie1eby c~1 1 1:·! un1:::r p·•:: • ··.o c' ' •:i:

that th 0 or~g rnlor~on_ rs lriie nnrl c.orrec!

. /t/J /f~r/{}il,c.J-' ;; /l/l'vj</' \. ~/~/!i---__ _

he"":>• Pnonc llom11t1 au,.in•1r. Hoc";~

Ca lPERS Benef1\ Services D1v1 s1on • ?O Sor. 9,;::711 ;)3cra1:1L .. !·~ : .•:r li • ,• '.• !_." ": · 1 --------~


AcaIPERS P.O. Box 942715 Sacramento, CA 94229-2715 888 CalPERS (or 888-225-7377) I Fax: (800) 959-6545 www.calpers.ca.gov

California Public Employees• Retirement System

August14,2014

Grantland L. Johnson . ; <

CalPERS ID:

Dear Grantland L. Johnson:

This is to confirm that your Beneficiary Designation form which was designated on 08/14/2014 9:32 am has been accepted by CalPERS.

Benefit Selection: Pro-Rata Lump Sum

Beneficiary(s): Lee A. Turner, Primary, 100.00%

We would like to remind you that if any of the following events should occur, your current designation will be automatically revoked:

Marriage or registered domestic partnership.

Dissolution or annulment of marriage or registered domestic partnership

if initiated after the beneficiary designation form was submitted.

Birth or adoption of a child.

Termination of employment that results in a refund of your contributions.

If one of these events should occur, a new beneficiary designation must be completed if you wish to name someone other than your statutory beneficiary(ies). The statutory order is: 1) Spouse or Registered Domestic Partner, or if none. 2) Children, or if none, 3) Parents, or if none, 4) Brothers and sisters, or if none, 5) Estate, if probated, or if not, 6) Trust.

ff you have any questions, please visit our website www.catpers.ca.gov or you may contact us toll free at 888 CalPERS (or 888-225-7377).

mytCalPERS 2172

' RESPONDENT'S

i uarr I

Page 1of1

Attachment G Respondent's Exhibit I Page 1 of 1

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i RESPONDENTS ; EXHIBIT

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Attachment G Respondent's Exhibit J Page 1 of 14

C001 1i ty Housing

ATTORN!Y'CRPAAT'I wm«IUTAYtoRla!tf~, --~ad~· MARK P. GROTEWOHL244060 LAW OFFICES OF MARK GROTEWOHL 1610 Executive court

FAX Ho. 1707759F~'\3 P. 009 OCT 1 7 2014

FL-180

Sac:temanto, CA 9!884 T&.1.l!PMOM!NO.: (918) 925-9180 S:AXJtO. ~ (916) 9.26-9182 NDORSEO IW.NLADDRllSG l0Ptksnr1}:

ATTOANeY FOR (MlmlJI Grantland L Johnson SUP&RIOR COURT 01' CAUFORNfA, COUNTY OF

sm&r AD~3341 POWER lNN ROAD ~UNG ADCMOe: -same 89 abave-

CIT'( AND lJP con!: SAcRAMeNTO. cA 95828 BRANCH NAME: WIWAM R. RIDGEWAY FAMJl.Y RELATIONS

MARRIAGE OR PARTnERSHIP OF PETITIONER: Grantland L Jonnson

RESPONDENr:Charfot Batten

JUDGMENT liJ DISSOLUTION

CJ Status only CJ LEGAL SEPARATION I:] NUWTV

Cl Reserving jurisdlctlon over tarmlniltlon of marltsl or dameatlc partnership statue

li:I Judgment an rwervad fsauea Date marHal or dame&tic; partnerahlp alatus ends:

OA8ENUM1St

13FL01863

1 2014

1. Cl ThJs judgment a contains peraonal conduct reattaining orders Cl modifies exiating rmtrainlng orders. The restraining ardel8 are contained en page{a) . of the attachment. They explra on (date):

2. This proceeding was heard as follows: Qil Default a" uncontested ~ By declaration wider Fem~y Cade sectton 2336 t:I Contastad CJ Agreement In court · a. Data: 0 EC 3 I 2014 WM NEIL SHrPHE~t9ept.: Room: b. Judicial ~car (name): COURT COMMIE;f.NER Cl Tempormy juclge c. Cl Petitioner present in ccun . Attemey i:iresent in COUit (llaf119): d. Cl Respoiidant preaent in court Cl Attorney s:iresent in court (nameJ: e. Cl Glalmant present in court (namt1}: CJ Attomey present in ccurt (name): f. Cl other (specify name}:

3. The court acquired jurisdlctfon of the respondent on (date): 5/Bfl013 e. liJ The respondent was sBl'Ved with process. b. CJ The respondent appeared.

THE COURT ORDERS. GOOD CAUSE APPEARING 4. a. CJ Judgment of dissolution le entered. Marital or domeistfc partnership status Is tennlnated end the parties are restored to the

status of single parsons (1) Cl on (specflydattJ): (2) Cl on a date to be detennlned en noticed motion of efther party or an stipulation.

b. r::J Judgment of legal s~SJ'Btian Is entered. c. Cl Judgment of nullity is en1ered. The partiee are declared to be single persons on the grcund of (spsciffj:

d. a This judgment wlll be entered nunc pro tune 88 of (date): e. 1iJ Judgment on resarwcl issues. f. The a petitioner's Cl respondents former name 18 restored to (specitY): g. Cl Jurfsdldlon is reserved over all other issu88, and all present ordera remain In eff'ect except ee provided below. h. Cl This judgment contains provisions for child support or family support. Each party must complete and ma with the court a

Child Support Case Registry Form (form FL-191) within 1 O days of the date of this judgment. Tite parents must notify the court of any change Jn the Information aubmftted within 10 days of the change, by ftllng an updated form. The Notice of Rights and Responslbifltles--Hoalth-care Costs and Relmbu1SSment Procedures WJd lnfommtlon Sheet on Changing a Chlld Suppott Order (farm FL-192) la attached. P.-1 on

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·" CASE NAME (Last nam&, tfrst name of each Johnson, Gtant1"1d v. Bolton, Chmlot

NIJMUER 13Fl01863

4. I. CJ Tho children of this marriage or domeetk; partnership are: (1) Cl Name Blr1hclate

(2) CJ Parentage la established for chUdren of this relationship bom prior to the mamage or domestic: partnership J. CJ ChUd CU8tody and Ylsltatlen (parenting time) are ordered ae aat forth in th9 llttached

(1) l:J Setilement Bgreemont. uttpulatfon for judgment. or other written agreement which contains the Information required by Family Code section 3048(e). .

(2) Cl Ch6d Custody and VISltalionOlderAttechmsnt(form Fl-341). (3) c:J Stipulfliion end Order for CU8tocly and/or VtsltBtlon of ChlldlfllJ (fOnn FL-355). (4) t:I Prevlaualy eetabllshed In another case. case number: Court:

k. Cl ChOd support is ordered as set forth fn the mtteched (1) Cl Settlement agreementi stlpulatJon for Judgment. or other Yll'tttBn agreement whld\ contains the declarations

required by Family Code secUon 4088(a). ·c2) Cl C/IHd Support lnf'onn8llon f!lnd Order Attachment (fonn R.-342). (3) CJ Stlpu/stlon to Establlsh or Madlly ChHd S&IPpart and Omer (fonn FL-360). (4) Cl Previously established ln another case. case number. · Court

I. 1iJ Spousal, domestic partner, or fanilY support 1s ordered: (1) Cl Reserved for future detennfnetion as relates to Cl pefftfanar Cl ra&p0ndent (2) CJ Jurisdlctftm termtnated to Oftfer 'spousal or partner support to 0 petlUoner Cl respondent (3) Cl ~ set forth In the attached Bpcusal, Palfner, or Family Suppott Order Attar:hm6nt (ferm FL .. 343). (4) [iJ As set forth in the attached settlement agreement. stipulation for Judgment. er othor written agreement. (8) l:J Other (specify):

m.li] Property divfslon is ordered as set forth In the attzched (1) 1iJ Settlement agreement, stipulation for judgment or other written agreement. (2) Cl Properly On:lsr Attachment to Judgment (fonn FL~34!). (3) CJ Other (spec;lfy):

n. lil Attorney fees and costs are ordered as set forth in the attached (1) iiJ Settlement agreement, ettpulation for judgment, or other written agreement. (2) CJ Attomey Fees 11nd Costs Order (fctm FL-348). (3) Q Other (spet;Jfy):

o. Cl Other (speclff):

Each attachment to this judgment Is Incorporated Into this judgment, and the partlee are ordered to comply with each attachmenrs provisions, Juriadiction Is reserved to make ether orders nece&SBTY to cany out this judgment.

Date:

5. Number of pages attached; ___ ,_( __ .IUDICW. OPP

~IGNAl\JRI! l"\JWlWS LAST AlTAQIUSNT

NOTICE

FL-180

Dissolution or legal soparatfon may automatically cancel tha rlght8 of a spouse or domestic partner under the ottler spouse's or domesuc partner's \\111, trust. retirement plan, power of attorney, pay..on-death bank account, transfer-on.c:teath vehide regfs1ratlon, survivorship right• to any property owned in ]clnt tenancy, and any other aimllar prcperty Interest. It doee not autcmaticatly cancel the rights of a spouse or domestic partner as beneficiary of the other spouse's or dc:mesttc partner"s life Insurance pcllcy. You should review these matters, as \veil as any credit cards. ether credrt accounts, Insurance palfcies, retirement plans, and credit reports, to detr:rmine whether they shcutd be changed or Whether you should take any ether actlone. A debt er oblfgstion may be assigned to one patty aa part of the dlssolutlan of property and debts. but if that party does not pay the debt or abUgatfon, the creditor may be able to coned from the other party. An earnfn.gs assignment may be msued wtthout additional prcof ff child, family, partner, or spousal support 18 ordered. Any party required to pay sul)port must pay Interest on overdue mnounts at -the Illegal nite, 11 which Is currently 1 O percent.

FL•1BD(Rw. JiAy 1, 20121 JUDGMENT (FamOyLaw)

~~ JOHNSON,GRANTI..ANO

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MARITAL SETil.EMlifNTAGBf!EMEN'[

I. INTRODUCTORY PROVISIONS

1.01. IDENTIFICATION OP PAR.TIES. This asmem= is made between GRANTL&'\fD · JOHNSON, hereafb:t mferred to as "Husband," and CHARLOT BOLTON, hereatler referred to

as ''Wife.", hereafter collectively refer.red to as the ''Parties".

1.02. DATE OP MARRIAGE. The parties were manied on Febrwuy S, 1975 and ever since then have been and are Husband encl Wife.

1.03. DATE OF SEPARATION. The dat= of separation of the parties was April 1, 2002., reaulting a marriage. of27 years 1 month in duration.

1.04. IRRECONCILABLE DIPFBRENCES. Ineconcilable ~es have led to the irremediable breakdown of the matriage, and there is no possibility of saving the marriage through counseling or other means.

l.OS. MINOR CHILDREN OF nm l\-IARJUAGE. There ara ~or chilcmm of the marriage. . -

1.06. CJRC'UMSTANCES OF THE PARTIES. Husband is 65 yems of age end fully retired. Wlfi: is 63 years old and is retired. Both J>A...rties have ~sting health conditions tbat affect their ability to tnallttain ~lo)lllent.

1.07. DISSOLUTION PROCEEDINGS. Husband filed a Petition for Dissolution ofMarriage on April 8, 2013in the Superior Court of Califomia, Coanty of Sacramento, Case Number 1JFL01863.

1.08. PU~SE OF AGRE!MENT. The pmpose of this agreement is to make a mw and complete stdement of all rights and oblig&tions between the parties, .lncludlllg all property rights, claims for ?:eimbursements end cxecli1S and spousal support. The Parties agree that this Agreement~ be incorpomed and other than 'those teJ'mS specifically excepted, merged into the Judgmcmt of Dissolution Re: Reserved bsues.

1.09. DISSOLUTION - STATUS ONLY. A Judgment of Dissolution-Status Only was previously entered by the court, 1z:miliJating the parties' marital status effective November 9, 2013.

D. SPOUSAL str.PPORT

2.01. ACKNOWLEDGMENT. The patties acknowledge and confinn the following facts.

a. This is long tenn mmiap subject to the provisions of Fam C § 4336.

b. Husband is voluntarily retired and self supporting. W':de is also voluntarily retired and self .. supporting.

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c. Husband is 65 yea?S old 21I1d in critically poor health with sC"Yer8l pro-existing physical issues liuJidng his abilfl1 tQ 'WOJ'k. Vtfe is 63 1"8!S old and in poor health with pr&-existins physical issues limiUng her ability to work.

2.02. W .A.IVER. AND T.ERMINA TION OF .JURISDICI10N. Based upon the ficts recited in. pmagraph 2.01 above and the addttiODBl factors set forth in Fam C § 4320{a)-(n), each party irrevocably waives the right to receive spousal support from the oths at any time. EiCJiParty futth~ i61Wminati0J1 of 1he court's jurisdic1ion to awmd spousal support to either party at llDY time in the future. AB of the eft'tdivc dat.e hereof, no court shell have jurisdiction to entertain an application for spousal support SQ.bmitted by either party. !be parties intend the foregoing to constitute fhe w.titten agremmmt teqaired by Fam C § 4336 to tenninate the Court's jurisdiction over spoµsal support.

2.03. WAIVER OF SPOUSAL SUPPORTBYBUSB.AND. Husband.has b=n advised of bis rights with tepid to spousal support. Husband adawwledges and understan~ he is under no compulsion to .irrevocably weiw the .right to subsequently seek spousal support from Wife or agree 10 terminare the court's ~ction 1D award him spousal snpport in the future; he does so Imowingly and voluntarily. Htisband farther undcmands that upon temlbmti011 of !Im court's jurisdiction ovcrr spousal support, no court ma.y grant a request for spousal sUpport regardless of circumstances or economic hardship which subsequently arise

2.04. WAIVBR OF SPOUSAL SUPPORT BY WIFE: W-lfe has been advised ofh~ • with regard to spousal support. W1fe aclmowiedges and understands she is under no compulsi · to iuevocably waive the right to subsequently seek spousal support iiom Husband or agree to terminate the courrs jurisdiction to award her spousal support in tbe future; silo does so knowingly and voluntarily. She !Urther understands tllat upon temdnation of jurlsdictiOD, no court may grant a request for spousal support rogardless of circumstances or economic hardship which subsequeatly arises.

ID.PROPERTY

3.01. CHARACTERIZATION. Husband and Wife agree that the assets and obligations of the parties are those set forth in Exhibits A and B attnched hereto. Some of the assets md obligations are community property and soJ1le m:e separate property; no disti=tiou is made as to their characteri7.ati because the parties have agreed on the ultimate division of property, regardless oi its ~haracterization as community or separate. Ho\\'e'Ver,, both parties reserve their respective right to submit evidence to 1he court, and have the court decide, ~ ~eparate or community property cbmacterlzation as commlmity or separate if this .Agreement is merged into and becomes a Judgment and such Judgment is subsequently set aside, in whole OJ: in part, as to the di'\lision of assets and/or obligation dcsaribod below, or in tho event that a creditor makes a claim oo the property of a party because of nOD.·P81J!1eDt by the other party of an obligation msigned to bimlh8r in the dMsion of assets and obligation.

3.02. WlFE'S PROPERTY .. WifC will be awarded and assignM tht assets and liabilities listed in Exbi"bit A atfached hereto and .incorporated herein as her sole and sepatate pmperty. HllSband hereby tmmfeis and 8.9Signs to Wife all of his rights and interest in each asset and

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• .. t • c obligation. Wife will pay all obligations assigned to her pursuant to &hlOit A and mdemnify. and hold Husbap.d hmnless from same inchmiDg all costs and attomey fees to ddmd any claims asserted bythe creditor.

3.04. HUSBAND'S PROPER.TY. Husband will be awatded and assigned. tho assets and · · ·. liabilities listed in Exhlmt B attached hereto end inoorporated herein. as his sole and sepm:ate property. W'tfe hereby txausib:s and assigns to Husband all ofher .tights and :interest in each sssc:t ancl obligation. Husband will pay all obligatioos assigned r.o lUm pursuant 10 Exblbit B inde.moffy and hold W"Jfe harmless from same fi:t.cluding all costs and a1tomey fees to defend any claims assenm by the creditot.

3.05. ADDTI10NAL CONSIDERATION. As additional consideration to Wife, Husband has paid and Respondent has received $900 in addition. to the assets Otbenvise assigned to Wife hereunder pursuant to Exhibit A. No further obligatiOll is o'Vring.

3.06. MUTUAL WAIVER OF APPJWSAL AND RIGHT TO EQUAL DIVISION. In atrfviDa at the valuation of such assets, each party relies on his and her own opinions and judgments as 1o the vahw of said property without reliance upon appraisld !lld hereby waives the right to an accounting and appraisal of assets and debts. The parties further aclmowledge 1he division of coDDOUDity property provided herem does not necessarily represent an equal division. but that each party has co~ that fact in mrtering into this apement. Accordingly, each party hmeby waives the right to an equitable division of the COXtlOllJDity property. The parties intend this mutual waiver of the right to an equal division of the community property to constitute tha tequirement of a written agreement by the parties set forth in Pam. C § 2SSO.

3.07. WARRANTY OF FULL DISCLOSURE OF EXISTENCE OF ASSETS. Each party wemmts to the other that he or she has no knowledge of any assets other than tbostJ disclosed and list!"i in £m"bit A and Exhibit B attached hereto and incoxpormd herein.

3.07.1. REMEDY FOR BB.BACH. If either party has knowledge of any asset other 1ban those disclosed and listed in this agreement, and such asset(s) is charactedzcd as commuoity property, that warrsntor will transfer or pay to the war.ran1ee, at the v.'Btl'&Jltee's election, one of 1he following:

(a) If the asset is reasonably susceptiole to division, a portion of the asset equal to the warrailtee' s iDterest in it;

(b) The fair market value of the wemmtee' s inttttest in the asset on the effective date of this agreemcmt, plus interest at the rate of 10 percent per amrum from the effeo1ive date to the date of payment; or

. (c) The fair mmket val1lc of the 'MU'l'B.lltee's interest in the asset on the date on whic.b.1he Wll11'8nke discovers the existence of 'the asset. pros inters at the rate of 1 O percent per annUJD from the cliacovery date to the date af payment.

This provision will not be dee.med to imp@tt the availabilii;r, in a court of competent jutisdic1ion. of any other remedy arising from nondisclosure of community assets.

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3.01. WARRANTY OP FULL DISCLOSURE OF EXISTENCE OP LJABILmBS. Eadl party WIUJllltl to 'the other that he or she mit1m has iDculrod. Dm' will m.cur. on or bo1bre 1he eJrective dam of 12ais apemmlt, any liabiliV not discloscc1 ad listed m this·~ OD which 1he other is or may become personally liable or1bat colJld be enb1:ed at any 'time against an asset bold orto bereceivedunderthls·~'bythe other patty.

3.08.1. RBMBDY FOR.BRBACH.. If either party has inamcd or does inour, cm. or befot9 the dective date of this agmement, eny liability not disclosed sad listed in 1Dis apement on which dm otheis or may become ptDscmally liable ar 1hat could be enfbrccc1 at any1ime against an asset held orw beJeceived tmder'this apemmt byibe other party, that wammtor ""11 fW1y indemnify the other wifh respect to the oblig&Dou, includiDg, but not limited to, any and an liability on the obligation. attmney fees, and relatecl oosts. This provision will DCJt be deemed to impair tbs availability, in a caurt of competent jlltisdic1ion, of any otheJ remedy arising from nondisclosute of such liabilities.

3.09. WAllR.ANTYllGAlIDING UNEJSCLOSED GIFTS OR. TRANSFSRS. ~party waaams 10 tbe other that he or she Jw not made any undisclosed. gifts ottransfms of any community assets with a &ir nurrbt value over S2SO for bstbau adeqwde ~ reasmable consideration without prior notice to the other party.

3.09.1. REMEDY FOR BRBACH. If either party has made any undisclosed gift or transfer for less than adequate comidmation of any r:ommnnlty asset with a lair mm:kot value over $2501Vithout the other party's knowledge, 'that wamntor will pay to the warrant= a sum equal to~ of the fidr mm:ket value of t1m eat uamfeued, with the fair market value to be dctmn"'ed, at the wauantce'.s election. as of rithar (a) the effective date of this agreement or (b) the date on whicb the wammtee discovas the tmufer, Im any appreciation in th= amet's value anxibutable solely to acts of the 1l'rmSfeJee(s) sad SDCcesaor(s). The -wanautor will

· furthef pay to the ww;zaotee interest at the rate of 10 percent per annum from th~ date elected for detemiination of the fair msiket value of 1he asset to "!le date of payment This provisiOJJ. will not be deemed 1D impair the availability. in a court of competent jurisdiction. of my other remedy arising from undisclosed gi£ta or tnmsb for less thaD. adequate coizsidcradon.

3.10. WARRANTY REGARDJNO AFI'BR-ACQUIRED LIABILITIES. Each party wmxants to the other 1hat he or she will not incur, atlor the effective date of tbis asreement. any liability or obligation far which the other will be or may become peis0ll8lly liable or that ~d be eufoteed aszllnst an essatheld by the other party.

3.10.1. RBMBDY FOR BREACH. If either party incurs, aftm the effective date of this agreement, any liability or obligation for which tU o1her will be or may become persrma11y liable or that could l=enfOJced against an asset held by 1be other party, that wammtorwill indemmffy the other for any liability on 1be obliptiou. attomey fees. and related costs.

IV. REAL PROEPRTY

4.01. The parties acquired daring the marriage oommutdty property interests in 1he real properties located st 228 Omst=ad Drive and 1 m Bannon Creek Drive. bath located in SMnlmemn, CA. Tb.e parties previonsly divided thoso hxte1ests br agreement. Accoxdingly, each

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party hereby in:evocably waives the ri,iht to assert any claim against the other with respect to the commu:aity property i.ntmest in either property, including, but not l.imited to those for reUn.~xnents, arcd:its or o:ffiiets.

4.02. Repayment or Refinance of Debts. All debts, secured and unsecured, assigned to a party by tlie terms of this agrmnent and for which the other party bas ongoing liability shall either be pai~ in full or otherwise refinanced by tbe party to whom the debt is assigned.

v. RETIREMENT BENEFUS

5.01 IDENTIF1CATION. Wife has acquired through employmcut an interest in the Sacramento County Employees Retirement System (SCERS) defined benefit pl.ao, 401 (k) and 457(b) defined contribution plan. Husbmd has acquired through his employment an interest in the Cilifomfo. Public Employees Retirement System (CalPERS) defined plan and 401(k) defined contribution plan administered by Amerifunds.

5 .02. WARRANTY. Each party warrants to the other that, to the best of bis or her knowledge after cbeclcing with his or her employer, he or she is not a participant or beneficiary in or with respect to eny pension or deferred compensation retirement plan other than those disclosed in section 5.01. Jf either party becomes a.ware of his or her eligibility for or participation in any benefit plan not disclosed in this agreement that is based in an.y degree on service during the m.aniage and before separat:fon, that party will notify the other party of the eximencc of that eligibility or participation and !llltharize the plan to provide to the other party any information neces.sary to calculate the community interest, treating that interest as an omitted asset subject to the continuing jurudictioo of the Court.

5.03. W AIYER. Under the terms ofthis agreement.~ entire interest of each plan specified in paragraph 5.01 above including, but not limited to, tho· right to future benefits and the right to. name a beneficiary for a.oy death and SU!Yivor benefits payable under the plan. is awarded to th~ party in whose name tl:ie in~ is maintained. the "Plan Participant". Each party is informed that, independent of his or her community inten:st under federal law or the tec:ns of the plan, he or she m.ay1 unless waived, have a right to survivor rights or other benefits in a plan awarded to the othm' party under the ~ of this agreement. Each party expressly waives all such rights and interests and will timely sign those documents required by the plan adminisrrator to implement the waiver, including written consent to designation of one or more alternate beneficiaries when applicable. This provision. does not waive any right expressly provided in any trust agreement or beneficiary designation executed by one party in favor of the other after the effective date of this agreement.

5.04. QUALIFIED DOMESTIC RELATIONS ORDERS. Since by the terms of this agreement ea.ch party is assigned the entirety of the community property iIItcrcst in his or b.er respective retirement benefits subject to ERlSA provisions, no Qualified Domestic Relations Order is required. Therefore, the parties' previous agreement to engage the services of Moon Schwartz md Madden to draft tbc qualified orders necessary to divide~ commmrity property interests in the parties• respective retirements is hereby :rescinded.

V. A'ITORNEYFEES AND COSTS

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5.01 NO ALLOCATION OR RBIMBURSBMBNT. Bach patty will bear all of his or her own attorney fees mJd costs immrred in connection with the negotia1icn, pxepaxation, and execation of 1his agreement and the pending proceeding for dissolution of maniage.

5.02 LEGAL REPRESENTATION. This agreement bas been prepared by Mark P. GJ.'Otewobl CSB#244050, attomey for Husband. W'lfe bas not been represented in the negotiation or preparation of this agreement Vlfe aclmowledges that Husband's attomey bas infonned her that tbe attomey represents only Husband, that W'tfe bas the right to obmin independent lesaJ. advice, and that Wife ~d do so, but that she voluntmily declined to obtain such advice. Vife fmthet acknowledges that she bas cmefully read this agreement in i1S entimy and vohmtan1y chooses to execute it

VI. GENERAL PROVISIONS

· 6.01. RELEASE OF LIABILITIES AND CLAIMS. Except as othenvise provided in this agteement, ==h paity hereby releases the other fi:om all interspousal obligations, wherher. incurred before or after 1he effective dam, and all claiDls to the property of the other. This :release extends to ell claims based on rights that have accrued before the marriage and during the marriage, including, but not limited 10, property and support claims, claims for reimbursements or credits p1U3UaDt Family Code § 2640, charges for exclusive use of commUDlty property after the date af separation (Mamage o/Watts), or:paymcnts on community obligations a:ftertbe date of separation (Mtrrriage :If Epstein). The parties have oonsidered and provided for such claims

"'m this agreement.

This release extends to all ~bums, whether known or unknown. that either party may have against tm other. B; initialing below, ea.ch party expressly 1J1.'Bives with resp=ct to the other the benefits of Civil Code §1542, which protects agsjnst the inadvertent waiver of material claims tbat one does not lm9w or suspect to exist, stated as follows: "A general release does not extend to clallns which the creditor does not know or suspect to exist in his or her favor at the time of executing the release. ~h if known by him or her must have materially affected bis or her settlement with the debtor.

(Wife's initials) (Husband's initials)

6.02. lNDEMNIFICATION. Each party shall indemnL.'} and hold the other hannlcss from all debts assigned to tho party by 'the terms of this~ including legal fees and costs m defense of an enforcement action brought by the third party creditor.

6.03. W AIYER OF RIGHTS ON DEA'ffi OF OTBBR. PARTY. Except for Wjfe's lights _ ·~ ·"f'·: • ·~ under paragraph 3 .02 a.f this agreemmt, each party hereby waives the tight to receive any .l . .• ~·. property or rights whatsoever on 1he death of the other, mtless such tight is created or affirm ~ /: by the other under a will ~ othci: written document ex:~cl ~the eifective ~ of this ·~~r. .... ; iff~ .. .. : .!Ji.

· agresment. ~party believes that he or she has received a fair and reMODablc disclosure of the 1t · ·t::!:r.Jl~t property and :financial obligations of the other party. Each party's-waiwr is intended to be an ~:. -:::.,, enforceablewahrcroftbatparty's rights undar Probst= Code §§140..147.

6

FEB-11-2015 02:59PM From: 17077596053 ID:CALPERS Paee: 016 R=95~


F!B/lli2015/WED 03:16 FM Ccr~mi ty Housing FAX Ho. 170775°c153

( c (.Of) M>

The rights waived include, but are not Wnited to, 'the following:

{a) Property that would pass from the decedent by intestate succession;

(b) P,operty that would pass from. the decedent by testamentary disposition;

(c) A probate homestead;

( d) The setting aside of exempt property;

(e) A family allowance;

(f) The setting aside of an estate;

(g) An election to 1*e commumty or qnesi-community property against the decedent's 'Will;

(h) The statutory share of an omitted spouse;

(i) An appointment as exeoutor or administrator of the dcccdmf s estate, ~cept as the nominee of a third party legally entitled to make such a nomination;

P. 0 l?

m Property that would pass from the decedent by nonprobats transfer, such as the survivonbip interest under a joint tenancy, a Totten tnJSt account, or a payable-on-death eccount;and

(k) Proceeds as beneficiary of any type of insurance policy.

6.04. ENTIRE AGREEMENT. This agreement contains the entire agreement of the parties on these mattm, superseding any previous agnsement between them.

6.0S. RBCONCILIA TION. 1f the parties reconcile, this agreement will :nevertheless remain in full effect unless and until it is modified orte'Voked m a writing signed by both parties.

6.06. MODIFICATION BY SUBSEQUENT AGREEMENT. This apen:ient JIJB.Y be modified by subsequent agreement of the parties only by ail instrument m writing signed by both of them, an oral agreement to the extent 1bat the parties execute it, or aJl m-court oral agreement made into an ordsr Dy a court of competent jurisdiction.

6.07. ATIORNEY FEES IN ACTION TO ENFORCE OR MODIFY AGREBMBNT. The prevailing party in any action or proceeding to enforce or .moclify anyprovisionoftbis agreement. or any corresponding pravision of a subsequent jndgmmt into which 1he provision is merged, will be awardednmsonable attomey fees and costs. For the moving party to be deemed the pxevailing party for purposes of this p.rovmon, at least 1 o days before the filing of any motion he or she mmt provide wrlttcm notice.to the o1hm' party specii;ing the alleged breach or default, if capable ofbeiDg cured, or the modification teqUCSted. The other party must then be

7 i·

FEB-11-2015 02:59PM From: 17077596053 ID:CALPERS Pue:017 R=95%

I I


. .. . ~~H/lliiUlJ/WKD 03: 16 FM CMununity Housing FAX No. l 7077h06J53 P. 018

. . .

.. . ... . , ........ , . c I O'O N~ ........... ..

allowed 1D avoid implementation of this provision by curing the breach or deffllllt specified or executing an agreement for the modification requested during the 1 ()..day period.

6.08. EFFECTIVE DATE. The effective date oftbis apmnent will be the dail: of its executiao. by the second of the parties to do so.

6.09. COURT ACTION. If ajudgment of dissolution of marriage is obtaiD.ed by either patty, the original of this agreement will be attached to b judgment The Court will bo requested to do the following:

(a) Approve the entire agxeement as fm and equitable;

(b) Order the parties to comply wi1h all of its executory provisions;

( c) Merge all provisions, except those relating to warranties and indemnifications, into the judgment; and .

( d) Incoiporate the remainder of the agreement in the judg1nent fOl' the sole purpose of idau:Wicatio~

Approved as eonfilrmlngto theagreem~

Date: 1ojrt/L1 · Mm.iGi0l"E'WOtfAttomey for Petitioner

IT IS SO ORDERED:

Date: QEC 3 1 2014 SUPBRIORCOURifunGE

8

. WM Nf\l SHFPl-lF.RO CO\lHT C'JMMlS~lONER

FEB-11-2015 02:59PM Fram: 17077596053 ID:CALPERS Pne:018 R=95'=

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...

~~H/l l!ZUl:>/WiV Uj: I'/ fM c..- iunity Housing FAX No.17077r~J53 P. 019

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NOTARYACXNO'WLEDClMBNT

StateofCallfomia )

Coumyof SJ:rcxiAA11ulo ~ ·On this _i day of ~ · , 2014, before me,l~IQ Q a'\ot VlrWl • Notary Public penoDBlly appeared Charlot Bolton who proved to me on the basis of satisfactoxy evidence to be

0

'tlie persoll whose name is subscniled t.o the within inm'um.eo.t muf acknowledged to me that she dxecuted the ~e in her authorized capacity, and tbst by ber signature on the

. iDBtrmnent the pemm, or the entity upon behalf af which the person acted, executed the instrument.

I certify under PENALTY OF PERJUltY under the 1aWB of the State of Califomia that the foregoing parasmpb is true ad correct.

~ •

LESLIE ROBINSON COP&t.. #2047118 !!I i ICV1UYP11Ul •CALNMIA §

i..-. Y YT~~~7~ Notazy Sea! Above ·~ Si~

9

FEB-11-2015 03:00PM From: 17077596053 IO:CALPERS Pne:019 R=95'=


. .,

~·!Bl lln U 1 J/WliV 0 3: 17 FM Cr -uni t y Housing FAX llo. 17077~"'·")53

(

EXHJBIT A

Assets and Debts Omfinned.tp Wife

1. .All clothing, jewelry, and other personal eifects in Wife's possessioli. ,

P. 020

2. All fumitare, appliances, artwork, tools and other personal property in Wife's possession.

3. All net proceeds from 1he sale of real property located at

4. All net proceeds from the sale of real property located a

S. 1989 Volvo Sedan

6. 2000 Dodge van and any and all insmance pmceeds received by Respondent.

7. All bank, credit union md in\.'CStmcmt accounts in W"tfets sole name and funds on deposit the.rein.

8. All rights and interest in 1he Physicians Life insurance Policy, policy number ending in

9. .AJJ.y a12d all interest in the County of Sacramento 4S7(b) account held in Wlfe's name alone, including but not limited to all member contnoutions and right91D future bemdits.

IO. Any and all inmrest in the County of Sacramento 40l(k) account held in Wife's llBOle

alone. including but not limited to all member con1ributions and rights to fua."U!e benefrts.

11. Any and all interest in the Sacramemo County Bmployecs Retirement System defined benefit retirement plan held for the benefit of Wjfe,

12. Any aud all student loan debt owed to the University of the Pacific.

13. All c.redit oard accounts in W"lfe's sole name eudrelated balances including bµtnot limited to.the. following:

a. Wells Fargo credit card in VJfe's J1ame alone. b. Meuic BSIJk credit card in Wife's .wmie alone c. HSBN Ordmd Bank credit card in W'lfe's name alone.. d. Bark1ay c=d:it card in 'Wm's name alone. e. Home ShoppUig NetWOrk credit card in 'Wife's neme alone.

FEB-11-2015 03:00PM From: 17077596053 ID: CR.PERS Pue:020 R=95'=

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~· ~8/ ll/201)/WED 03: 17 F1! Cr- "lun ity Hous ing FAX Ho. 17077~ ni;J53 P. 021 ... · ·· ·· .. ........ .... .. ..... .

. .. ··-· ... . · ·~ ~· \ .. . ''.. ", . .... ,: . . ·-1 OD ~ .. 9.. •. , .. ...... .. l~.~ .... .. ..... . .. , ..... .... .. . .. ...... . . ... ..... -. .. . ( •.

EXHIBITB

A.ssets and Debts Confomaj 1-0 Hunb@d

1. All clothing, jewelry, and other personal effeota in Husband's possession.

2. All furniture. appllimces, artwork, tools end other personal property in Husband's possession.

3. All savings, checking and crectitunion accoums held in Husband's sole name and balances therein, including but not limited to accounts at Bank of America and Golden One.

4. All rights and interest in the Arnerifunds 401\K) account number ending in :,, .. .. .

5. Any and all iatm:st in the CalPERS defined plen a!trlbutable to Husband's employment, including but DQtl.i.ti;iitcd..to.all.momber CODJ:n"butions and rights to pll!t erui future benefits, .survivor and demb. ~enefi~ ~c ~etitianer is 6.D.titled to select and assign "' according to the terms of the plan.

.. ' 6. Any and all Stu~ ~owing10-csus . ._ ·

7. .4.Jzy and all Federal and California State tax obligations owing for the ta."! years 2007, 2008 and 2009.

8. Any lllld all debt owod on the Bank of America. visa credit cazd in Petitioner's name alone.

9. Any and all debt owingto Nelson Kynaard-Ford Mortor Company.

10. Any llll.d all debt owing on the American Express credit card in Petitioner's name alone.

1 ! . 1'.JJ.Y and all debt owing on the Golden One Credit Union credit card account in Petitioner's name alone.

.., ... ·~ .

. i l I I I

I

I I I

i I i

FEB-11-2015 03:00PM From: 17077596053 IO:CALPERS Page : 021 R=95l:


E B/ I 1/ 201i!WED 03: 10 FM Cr .in ity Hous i ng

February 11, 2015

Cal PERS PO Box 942715 Sacramento, CA 94229-2715

RE: TIJD No

CalPERS Death Benefits Division:

FAX Ho. 17077'. ~53

I ~ ljj\ 1-::J ~ rr----

FEB I

GALPER~ ..... - . 4 /AGE "·~ ·

P. 002

Enclosed please find the Certified Flnal Judgment <5n Property in the Marital Settlement and Agreement for Grantland L. Johnson in the case of Grantland Johnson V. Charlot Bolton (December 31, 2015)

The bifurcation was completed in November, 2014 (which CalPERS has on file) and this Is the certified final property settlement judgment. This was held up due to lack of clerical staffing in the courts. lt is my understanding from a call I made to CalPERS prior to Chrlstmas that the analyst was awaiting this judgment in order to complete the process related to Lump Sum Death Benefit and payment of other monthly death benefits to beneficiary, designated by Grantland Johnson mid-August, 2014 before his death on August 19, 2014 which is In his file. I have enclosed copy again plus the Power of Attorney, designating myselt, his wife as POA and Executor.

In addition, I am encloslng most of the pay stubs from my husband's retirement checks from December, 2013 through September;-, 2014. Grantland's exwife had put a lien on his retirement checks while the property settlement was In progress, in the event that she might receive a portion. 50% was withheld monthly d.uring that period. The judgment (enclosed) was not in her favor. l cannot locate the stubs for June, July, and August, 2014 although they were received. My husband was Ill at the time, on dialysis, and spent the latter part of July and all of August until the 16th in hospital when I brought him home to pass away in our home. The amount withheld most likely equals that of the previous month of May, 2014 and the amount shown on the September, 2014 stub. In total, l estimate the withheld amount to be a little more than $6,000. Grantland wanted me to have this to pay off the cost of his funeral and not be burdened with this expense.

Once you have reviewed the certified final judgment, please issue the disbursement of the lump sum and the past retirement to his stated b eneficiary, myself. I have included his will of 2012 naming me his Power of Attorney and his Executor- as Dr. Lee Turner-Muecke, which was my name at the time, prior to our marriage on November 15, 2014. I have enclosed both a copy of the will, and I have verified our marriage certificate which is already in your file with his death certificate and application for both lump sum and application information for other monthly benefits, sent to me by Ca!PERS and returned completed In September 2014, shortly after his death.

In addition, I was on his Medical/Dental plans and recently found out thac I was removed because the final certified property Judgment was delayed due to court staffing and without that property settlement everything to do with his estate was closed down. This has been shocking and an extreme hardship to me as his wife

k

~ RESPONDENT'S

i h\'BIT ~ Cl. FEB- 11-2015 02:53PM ID:CA!...PERS From: 17077595053 Pa9

Attachment G Respondent's Exhibit K Page 1 of 2

.....

F!B/11/2013/WED 03:10 FM Co· nity Housing FAX Ho. 170775(\",53 P. 003 .. '

and previously domestic partner since 2008. I believe Grantland is Tier 1 and signed Option 2 for monthly benefits to surviving spouse. As such, I would be eligible for his Medical/Dental plan for life. I anxiously await word from you on this matter, as it has been vezy very stressful to me.

Thankyou for your attention to this business, as I continue to work on his life closure. It has been an enormous loss after our ten years together and I am very appreciative of the manner in which CalPERS has worked with me to make what is very difficult, somewhat more bearable. Should you need to reach me, the best phone number in your file to reach me is my cell, 916 .. 5 24-87 45.

Thank you and I look forward to hearing from you.

Sincerely,

*faJatUAf9'1t~ Dr. Lee Turner Johns/

FEB-11-2015 02:53PM From: 17077596053 ID:CALPERS Page:003 R=95~

Attachment G Respondent's Exhibit K Page 2 of 2

...

February 14, 2015

Cal PERS PO Box 942715 Sacramento, CA 94229-2715

RE: JUD Ne

CalPERS Death Benefits Analyst:

This package has been faxed in entirety to the Death Benefits Division on Wednesday, February 11, 2015. I am now sending the hard copy with a cover to address the fact that there seems to be some notation that in spite of my husband Grantland Johnson choosing Option 2 and further having signed the Application to Change Beneficiary on his Survivor Benefits, that I would only receive Lump sum. I have therefore put the two documents he signed August 13 while in hospital for both Jump sum and Application to change Survivor Benefits Beneficiary. Although we were married in 2013, there was a final property settlement on his former marriage pending. Enclosed please find the Certified Final Judgment on Property in the Marital Settlement and Agreement for Grantland L. Johnson in the case of Grantland Johnson V. Charlot Bolton (December 31, 2015). You will find that my husband was granted full and complete rights to name his own beneficiary with no amount of any property being assigned to his former wife. That had already been settled.

Grantland signed the Lump Sum Death Benefit and payment of other monthly death benefits to beneficiary, designated by Grantland Johnson in August, 2014 before his death on August 19, 2014 and we certified mail for you to receive originals which are now in your file. At that time, he and I talked with a CalPERS representative who assured him that his wishes would be honored even if after his death. In fact, I also had him sign a second copy of each and do have original signatures on both the Lump Sum and Survivor Benefits forms. In addition I am also his Executor (encJosed).

In addition, I am enclosing most of the pay stubs from my husband's retirement checks from December, 2013 through September, 2014. Grantland's exwife had put a lien on his retirement checks while the property settlement was in progress, and 50% was withheld from December, 2013 through September, 2014. The judgment (enclosed) was not in her favor. I cannot locate the stubs for June, July, and August, 2014 although they were received. My husband was ill at the time, on dialysis, and spent the latter part of July and all of August until the 16th in hospital when I brought him home to pass away in our home. The amount withheld most likely equals that of the previous month of May, 2014 and the amount shown on the September, 2014 stub. In total, I estimate the withheld amount to be a little more than $6,000. Grantland wanted me to have this to pay off the cost of his funeral and not be burdened with this expense.

Once you have reviewed the certified final judgment, please issue the disbursement of the lump sum and the past retirement to his stated beneficiary, 0

~t: am z:c 2 r.1-; ..

RESPONDENT-000048 m -

Attachment G Respondent's Exhibit L Page 1 of 2

myself. I have enclosed both a copy of the will, and I have verified our marriage certificate which is already in your file with his death certificate and application for both lump sum and application information for other monthly benefits, sent to me by CalPERS and returned completed in September 2014, shortly after his death.

In addition, and of great importance, I was on his Medical/Dental plans (CalPERS statement enclosed) and recently found out that I was removed because the final certified property Judgment was delayed due to court staffing and without that property settlement everything to do with his estate was closed down. This has been shocking and an extreme hardship to me as his wife and previously domestic partner since 2008. I know Grantland signed Option 2 for monthly benefits to surviving spouse. As such, I would be eligible for his Medical/Dental plan for life. I intently await word from you on this matter, as it has been very very stressful to me. Somehow those I have spoken with do not seem to notice that his beneficiary changes were made and signed before his death so I am therefore eligible for montly benefits and medical/dental benefits. I have consulted with an attorney in this matter.

Thank you for your attention to this business, as I continue to work on his life closure. It has been an enormous loss after our ten years together and I am very appreciative of the manner in which CalPERS has worked with me to make what is very difficult, somewhat more bearable. I would appreciate communication at your earliest convenience; the best phone number in your file to reach me is my cell,

Sincerely,

fh;1;;11Jua t;fftut~ Dr. Lee Turner Johnson

Wife of Former Secretary, Grantland Lee Johnson, Secretary, Health and Human Services Agency, State of California, Governor Davis Administration and,

Former Regional Director, Region IX, Health and Human Services Agency, President Clinton Administration

RESPONDENT-000049

Attachment G Respondent's Exhibit L Page 2 of 2

A CalPERS

California Public Employees' Retirement System Benefit Services Division P.O. Box 2056 Sacramento, CA 95812-2056 TTY: (877) 249-7442 (888)Ca1PERS (225-7377)phone; (800) 959-6545 fax www.calpers.ca.gov

February 17, 2015

Dr. Lee Turner Johnson

Re: Marriage of Grantland Johnson and Charlot Bolton

Dear Or. Johnson,

Reply to: Section 420

CalPCRS ID:

Thank you for your letter dated February 11, 2015 along with a copy of the Judgment on

Reserved Issues, filed December 31, 2014, pertaining to Grantland Johnson's retirement benefits with CalPERS.

Based on the Judgment, Mr. Johnson was awarded the entire interest in his CalPERS pension .

Therefore, we are removing the community property cla im on behalf of Charlot Bolton's behalf.

Mr. Johnson's case is being referred to our Death Benefits Unit to continue processing death benefits on behalf of our member.

Please note, for security purposes, all communications with CalPt:RS must identify the

member's full name, date of birth, and Social Security number or Cal PERS ID number.

We are here to assist you. If you have any questions, please visit our website at www.ca lpers.ca.gov, or you may call us toll free at 888 CalPERS (or 888-225-7377).

Sincerely,

Sylvia Stuart Commun ity Property Unit

cc: Charlot Bolton Mark P. Grotewohl, Attorney at Law

~ RESPONDENTS i EXHIBIT

i \!l\

Attachment G Respondent's Exhibit M Page 1 of 1

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Ian J. Barlow (State Bar No. 262213) KERSHAW, CUTTER & RA TINO FF, LLP 40 l Watt A venue Sacramento, California 95864 Telephone: (916) 448-9800 Facsimile: (916) 669-4499 Email: [email protected]

Attorneys for Respondent

BOARD OF ADMINISTRATION

CALIFORNIA PUBLIC EMPLOYEES' RETIREMENT SYSTEM

In the Matter of the Appeal Regarding Death Benefits Payable Upon the Death of GRANTLAND LEE JOHNSON by

LEE TURNER JOHNSON,

Respondent.

CaseNo. 2015 .. 0373 OAH No. 2015081045

NOTICE OF AMENDED DECLARATION AND AMENDED DECLARATION OF HERBERT L. ANDERSON

Hearing Date: October 6, 2015 Hearing Location: Sacramento

18 NOTICE OF AMENDED DECLARATION

19 The amended declaration of Herbert L. Anderson set forth below will be introduced as

20 evidence at the hearing in Jn the Matter of the Appeal Regarding Death Benefits Payable Upon

21 Death of Grantland Lee Johnson by Lee Turner Johnson, Respondent, Ref. No. 2015-0373.

22 Herbert L. Anderson will not be called to testify orally and you will not be entitled to question

23 him unless you notify Ian J. Barlow at the law offices of Kershaw, Cutter & Ratinoff, LLP, 401

24 Watt Avenue, Sacramento, California 95864, that you wish to cross-examine him.

25 111

26 Ill

27

28

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-1- 0

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~--m NOTICE OF AMENDED DECLARATION AND AMENDED DECLARATION OF HERBERT L. ANDERSON a:

Attachment G Respondent's Exhibit N Page 1 of 3

1 AMENDED DECLARATION OF HERBERT L. ANDERSON

2 I, Herbert L. Anderson, declare as follows:

3 1. I have personal knowledge of the matters set forth in this declaration. If called

4 upon as a witness I would be competent to do so, and could and would testify as to the truth of the

5 facts below. I give this declaration freely and in support of Respondent Lee Turner Johnson's

6 appeal of the California Public Employment Retirement System's ("CalPERS") denial of

7 Grantland Johnson's Option 2 lifetime monthly benefits to Lee Turner Johnson.

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2. I was a close personal friend of Grantland Johnson. I first met him in elementary

School, we were debate partners in high school, and we remained in close contact off and on

throughout his life. I was best man at his wedding when he married Lee Turner Johnson.

3. I was by his side in the Intensive Care Unit ("I CU'') during the several days and

weeks before he died.

4. During this time, Grantland Johnson was under constant medical supervision,

undergoing frequent medical procedures, could not read, and in tenninal health.

5. While at the ICU with Grantland Johnson in early August 2014, I witnessed

Grantland Johnson and Lee Turner Johnson review and complete the Post Retirement Lump Sum

Beneficiary Designation and Application to Modify Option and/or Life Option Beneficiary forms.

I also witnessed Grantland Johnson sign both of those forms.

6. As part of Lee Turner Johnson's efforts to explain the forms to Grantland

Johnson and correctly complete them, I also witnessed Lee Turner Johnson's telephone call to

CalPERS on or around August 5, 2014 during which she conveyed Grantland Johnson's health

condition, explained that he was attempting to complete the Post Retirement Lump Sum

Beneficiary Designation and Application to Modify Option and/or Life Option Beneficiary forms,

and requested guidance for completing those forms. As part of that telephone conversation, I

heard Lee Turner Johnson convey to Grantland Johnson that the CalPERS employee told them

that they should "not worry" and that "his wishes would be honored, no matter what," or

representations to that effect.

7. I knew that the purpose of the forms was to designate Lee Turner Johnson as the

-2-



1 new beneficiary for Grantland Johnson's CalPERS benefits, including for lifetime monthly

2 benefits.

3 8. Based on my knowledge of Grantland Johnson and his relationship with Lee

4 Turner Johnson, it is my firm belief that by completing the Post Retirement Lump Sum

5 Beneficiary Designation and Application to Modify Option and/or Life Option Beneficiary forms,

6 he thought and believed that he was effectuating the designation of Lee Turner Johnson as a new

7 beneficiary for his CalPERS benefits, including for lifetime monthly benefits, upon his death.

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9. As soon as the fo1ms were completed and signed, Grantland Johnson asked Lee

Turner Johnson to mail the forms to CalPERS immediately. Lee Turner Johnson then left to

deliver the fonns while I remained at the ICU with Grantland Johnson.

1 declare under penalty of perjury under the laws of the State of California that the

foregoing is true and correct. Executed this_ day of October, 2015, at------

California.

-3-



ome Participant Business Partner Admin Workflow my Toolbox

mmary Balance Record Maintenance Receivables Reports

mm on ;ks

nu

arch

0. Participant Name: Grantland L Johnson

~ Notes Search Criteria

ti. Notes Search Results Ad.Shcv•

CalPERS ID:

!mber Elections

pture Cateoory Type Note

Last Updated Last Uodatec

:eraction :ormation

blications :1ering List

blications ;tory !W Service ;tory

!

Legal Office

1fil@l Office

I Death

Date Bv

OAH Hearing set for October 6, 2015 @ Participant

9:00 a.m., in Sacramento

On 4/2/2015 This Appeal Case has been Participant assigned to Attorney Preet Kaur. Please

refer appeal inquiries to her at 795-1054.

The Death Benefits Appeai has been

09/02/2015

09/02/2015

Participant Assigned to Attorney Preet Kaur. Please 05/06j2015

Participant

Participant

Participant

Participant

refer Appeal Inquiries to her at 795-1054.

This Appeal Case Was Received in the Legal Office on 4/8/2015, and will be Assigned to an Attorney. Until an Attorney is Assigned, Please refer Appeal Inquiries to Lega!'s Main Line: 916-795-3675.

< >

Letter acknowledging appeal mailed to spouse.

Death file to Melissa to hold.

Request for Legal Assistance routed to Legal Via Keith/Diane.

04/20/2015

04/03/2015

04/03/2015

04/03/2015

CalPERS rcvd spouse's letter appealing our 0410312015 Participant determination on 4/2/14.

File to Melissa Cisneros for holding for a 0311012015 Participant possible appeal.

Released PR benefit to Lee (

Released CP Pend funds to Lee Participant (

Overpayment deduction of $592.52 applied to bene's warrant.

< )

03/09/2015

File to Lydia to expedite payment of the CP 03109/_?0lS Participant held money and the Prorata.

L. Okamoto I

L. Okamoto I

L. Okamoto I

L. Okamoto/

M. Cisneros I

S. Day-Bolar I

S. Day-Bolar I

M. Cisneros I

L. Chong I I

L. Chong I I

C. Beck I I

Attachment G Respondent's Exhibit O Page 1 of 3

~ ~ Unable to Participant Per caller inquiry about the way to 08/06/2014 K. Abram/ l Verify complete the application to modify option Caller and/or life option beneficiary, I assisted

with general information about competing the form and advised of the timeframe for processing.

Benefit Rejected BEne request received

Pavments Participant 7.3.14;CalPERS form needed. Reject letter 07/25/2014 R. Jenkins / I sent.

Page one of the dep KPSA Group election

Unknown Workflow form with missing ALPHA from the Medicare 06/18/2014 T. Lepisto I I Claim Number.

< >

Health Deduction Team: Called and spoke w/spouse, advised the $104.90 Medicare overpayment is correct. Advised 3/1/14 warrant mbr was already given a Medicare

Health Reimbursement of $104.90. But on the

Enrollment Workflow 5/1/14 warrant, we did a time time adj and 06/15;'2014 E. Navarro I I

(+) CRM mbr recv $209.80 instead of $104.90. Agreed to pay a 1 time deduction on the 8/1/14 warrant to satisfy OP Receivable ID

. Sent request to set up deduction.

< )

The Medicare Administration mailed a letter to notify spouses that are enrolled in the Kaiser Medicare plan with CalPERS, to notify them of their requirement to submit and verify enrollment in the Medicare

Health Participant Advantage plan "Senior Advantage". Did 06/05/2014 M. Countryma Medicare not respond to letter, will be canceled

8/1/2014. NOTE: Do not reinstate health plan unless member show proof of enrollment into Kaiser "Se_nior Adva.~tag~'~.

> <

CSOD -Workflow

Reviewed by CSOD Training Unit - Mbr and Member

CRM forwarded to Health Enrollment Inquiry for 06/05/2014 J. Dolar I I

(+) further review.

Mbr called and gave permission for us to

Benefit talk to wife, Lee Turner Johnson. Mbr had

Payments Participant questions in regards to his medicare 05/15/2014 D. Sanui I 1 reimbursement on his recent warrrant. Transferred to IAA.

Health Participant 05/12/2014 J. Reveles I I Enrollment Rec'd copy of sps' Medicard w/ both Part

...... A/B eff dates. Confirmed w/ mbr that sps hasn't used services. Advised eff date for sps' dep h/cov will be 5/1/14; Part B eff date is 4/1/14, doc rec'd 4/15/14.

Advised mbr a confirmation will be sent ar~ Kaisei will send medical cards for sps ..., .•. :.L-.:- ~ ···--··-


,.

~ E..l:'.. by 11/30/2013, participant will be canceled 12/1/2013. NOTE: Once canceled, do not reinstate coverage unless proof of enrollment into Kais~r "?~ni_~~ ~~y_!)_f1~_age''.

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Commun it~ Notice of Acknowledgement has been sent

Propertv Participant to Neutral Atty Jolene M. Pasztor and copy 08i22/2013 R. Abelia I I to DMC.

Unknown Worleflow Enrolled member in a Medicare plan eff

08/19/2013 T. Lepisto I I 9/1/13

spouse was extremely upset about the dev project & kept saying that the court has ordered calpers in the beginning of the cp case that the spouse be kept on. I tried to explaine that yes, calpers recommends that the spouse stay on but it is not court

Health ordered untill the final judgement is

Enrollment Participant finished. She stated that she had been told 06/21/2013 C. Freeman I by her friends that calpers is court ordered in the beginning of process. She hung up on me while I was exp:aining for the 3rd time about the dev project & that she may be inadvertedly deleted until project is finished.

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Per request of spouse, Charlot Bolton (CID: ), provided 2013 COBRA rate

Health Participant ($621.53) and advised Charlot that with a 06/13/2013 C. Keil I I Enrollment divorce, FS would be eligible to stay on

COBRA for up to 36 months. < >

Unknown Workflow Tax withholding form signed 3/19/2013 -

04/25/2013 M. Vong I I approved.

Benefit Participant

Mbr requesting change of beneficiary and 02/15/2013 D. Drummond

Pavments tax witholding.

Health P rt· . .. Mbr requestino change of FS to DP. 02/15/2013 D. Drummond Enrollment a icipanL Transferred to"' !AA

Informed mbr cannot enroll DP until copy of divorce decree is submitted to delete soon to be ex-spouse. Once deleted, advise

Health Participant the member to submit copy of the marriage 02/15/2013 G. Saldana/ I

Enrollment certificate, spouse's birth certificate and SSN, along with a signed written request to enroll spouse to health/dental plan.

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Unknown Workflow address changfe request already been 12/05/2011 H. Doubikin I updated

Unknown Workflow 21/01/2011 D. Coieman I
