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PUBLIC SAFETY PERSONNEL RETIREMENT SYSTEM CORRECTIONS OFFICER RETIREMENT PLAN

ELECTED OFFICIALS' RETIREMENT PLAN

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Mark Steed . i Dave DeJonge Deputy Administrator

Jared A. Smout Administrator Chief Investment Officer

November 30, 2018

PHILIP BRAILSFORD 9533 E OLLA CIR MESA AZ 85212-1417

RE: Benefit ID: 0180818 Accidental Disabi lity (under 20) Benefit 38-911/18 AMEND

Dear Philip Brailsford:

We have been authorized by the Mesa Police Department Pension Board to pay you an accidental disability retirement benefit in the amount of $2,569.21 per month. You will be eligible to receive this amount for as long as you maintain eligibility in accordance with Arizona Revised Statute §38-844 (copy enclosed). Your disability benefits are excluded from gross income per IRS Code Section 1 04(a)(1.). This is in accordance with Revenue Regulation 1.104-1, and Revenue Rulings 68-10, 72-291 , 72-45, and 80-84.

Your benefit is payable on the last business day of the month. It will either be deposited to your account or sent by check from our custodial bank, Wells Fargo, at that time. To view your detailed monthly deposit statement, please log into our Members Only application via www.psprs.com. Enclosed you will find step by step instructions on how to access th is application.

During this period of time, should your eligibility for an accidental disability retirement cease prior to your normal retirement date, your last employer is NOT REQUIRED to return you to covered employment. Such occurrences are considered on a case-to-case basis. At the appropriate time, should it become applicable, please contact your Local Board for further information.

For your records, please find the enclosed information regarding your retirement benefits should you return to work in any capacity with an employer of the Public Safety Personnel Retirement System, per Arizona Revised Statute §38-849. If you have any questions, please contact your Local Board.

As a new retiree, your eligibility for the cancer insurance program continues after retirement, for a period equal to five months for each year of credited service (A.R.S. 38-644). We have calculated your eligibility expiring on December 31, 2019. However, if you are already receiving benefits under the program or are diagnosed with cancer prior to that date, you may continue coverage by paying the annual premiums yourself directly to the program. If you meet the requirements to continue coverage beyond your exp(ration date and desire to do so, please contact our office at least one month prior to that date.

Retirees of PSPRS, CORP and EORP are eligible for the Arizona State Retiree Group Health Insurance benefits. Retirees must submit an appl ication to PSPRS to receive these benefits at the time of retirement, through the annual open enrollment process, or if the retiree has a qualifying event and the change is requested within 31 days of the event. Insurance elections or changes (non-Medicare) must be received by the 1Oth of the month to be effective in that month. Medicare el igible members must submit in the month prior to the effective change. For more information, please visit www.psprs.com.

301 0 East Camelback Road Suite 200 • Phoenix, AZ 85016-4416 • Phone: 602-255-5575 • FAX: 602-255-5572 • www.psprs.com

Any changes to your retirement information must be submitted on appropriate forms which are available onlirie at www.psprs.com, under 'Retired Members, ' 'Common Change Forms' or by calling our benefits department. We cannot accept changes by phone. You may also change your mailing address, bank account and taxes under'our Member's Only application via www.psprs.com. All changes must be received by our office by no later than tbe 1Oth of the month to be effective in that month.

If you have any questions or if we can be of further assistance, please do not hesitate to contact our office.

Sincerely,

Retired Members Department

Enclosures cc: MESA POLICE DEPARTMENT

20 E. MAIN STREET, #150 P.O. BOX 1466 MESA AZ 85211

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3010 East Camelback Road Suite 200 • Phoenix, AZ 85016-4416 • Phone: 602-255-5575 • FAX: 602-255-5572 • www.psprs.com

OFFICE OF CITY CLERK

CITY OF MESA, ARIZONA

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ARIZONA PUBLIC SAFETY PERSONNEL RETIREMENT SYSTEM LOCAL PENSION BOARD MEETING- POLICE

SEPTEMBER 13, 2018

A meeting of the Public Safety Local Police Pension Board of Mesa, Arizona, was held in Personnel Conference Room 2, 20 E. Main Street, 1st Floor, on September 13,2018 at 4:00p.m.

MEMBERSPRESENT MEMBERSABSENT

Bryan Raines, Chairman None Chris Brady, City Manager Barbara Jones, Citizen Member Stephen Lentz (Police) Ryan A. Russell (Police)

POLICE PENSION BOARD

STAFF PRESENT

Dee Ann Mickelsen, City Clerk Vanessa Wisneski, Sr. Program Asst.

OTHERS PRESENT

Kathryn Baillie Philip Brailsford (Applicant) Samantha Egan David Niederdeppe Nathan Peterson

(The Local Police Pension Board recessed at 4:01 p.m. in order to convene an Executive Session and reconvened the Public Safety Local Police Pension Board meeting at 4:14p.m.)

(The Local Police Pension Board recessed at 4:17p.m. in order to convene an Executive Session and reconvened the Public Safety Local Police Pension Board meeting at 4:28p.m.)

1. Discuss and consider the Accidental Disability Retirement application of Police Officer Philip Brailsford.

Chairman Raines welcomed Police Officer Philip Brailsford and his attorney Kathryn Baillie to the meeting. He advised Officer Brailsford that the members of the Local Board have reviewed his application and medical records. He outlined the process that would be followed by the Board and encouraged the members to pose any questions they may have regarding Officer Brailsford's pending Accidental Disability Retirement application.

All discussion relative to Officer Brailsford's disabling injury and subsequent treatments occurred in executive session only.

Boardmember Russell asked Officer Brailsford when he was reinstated with the City. Officer Brailsford was unsure of the date.

Boardmember Brady left the meeting briefly to verify the date with Human Resources. Upon his

Public Safety Local Police Pension Board September 13, 2018 Page2

return, Boardmember Brady indicated that Officer Brailsford was reinstated on August 27, 2018. Chairman Raines stated that in view of the absence of further questions from the Board, he would entertain a motion relative to this case. ·'

It was moved by Boardmember Russell, seconded by Boardmember Lentz, that Acciqental Disability Retirement applicant, Police Officer Philip Brailsford, be sent to Local Board Physi.cians for Independent Medical Evaluations.

Upon tabulation of votes, it showed:

A YES - Brady-Jones-Lentz-Raines-Russell NAYS- None

Carried unanimously.

2. Adjournment.

Without objection, the meeting of the Local Police Pension Board adjourned at 4:30 p.m.

I hereby certify that the foregoing minutes are a true and correct copy of the minutes of the Public Safety Local Police Pension Board meeting of Mesa, Arizona, held on the 131h day of September, 2018. I further certify that the meeting was duly called and held and that a quorum was present.

vw DEE ANN MICKELSEN, CITY CLERK

OFFICE OF CITY CLERK

CITY OF MESA, ARIZONA

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ARIZONA PUBLIC SAFETY PERSONNEL RETIREMENT SYSTEM LOCAL PENSION BOARD MEETING- POLICE

OCTOBER 8, 2018

A meeting of the Public Safety Local Police Pension Board of Mesa, Arizona, was held in Conference Room 170 W, 20 E. Main Street, 1st Floor, on October 8, 2018 at 10:04 a.m.

MEMBERS PRESENT

Bryan Raines, Chairman Chris Brady, City Manager Stephen Lentz (Police) Ryan A. Russell (Police)

MEMBERSABSENT STAFFPRESENT

Barbara Jones, Citizen Member Dee Ann Mickelsen, City Clerk Vanessa Wisneski, Sr. Program Asst.

OTHERS PRESENT

Kathryn Baillie Philip Brailsford (Applicant) Cynthia Kelley David Niederdeppe

Chairman Raines excused Boardmember Brady from the beginning of the meeting; he arrived at 10:05 a.m.

POLICE PENSION BOARD

(The Local Police Pension Board recessed at 10:05 a.m. in order to convene an Executive Session and reconvened the Public Safety Local Police Pension Board meeting at 10:14 a.m.)

(The Local Police Pension Board recessed at 10:14 p.m. in order to convene an Executive Session and reconvened the Public Safety Local Police Pension Board meeting at 10:24 a.m.)

1. Discuss and consider the Accidental Disability Retirement application of Police Officer Philip Brailsford.

Chairman Raines welcomed Police Officer Philip Brailsford and his attorney Kathryn Baillie to the meeting. He advised Officer Brailsford that the members of the Local Board have reviewed his application and medical records. He outlined the process that would be followed by the Board and encouraged the members to pose any questions they may have regarding Officer Brailsford's pending Accidental Disability Retirement application .

Chairman Raines advised Officer Brailsford that the Local Board has reviewed the independent medical evaluations of Dr. Lisa Jones and Glenn Clouse, Psy. D. He indicated that while Dr. Jones and Mr. Clouse disagree with each other regarding the condition permanently preventing Officer Brailsford from performing a reasonable range of duties, the Local Board must rely on Dr. Jones's evaluation to be in accordance with statute requirements. He noted that Dr. Jones is in

It

Public Safety Local Police Pension Board October 8, 2018

·[ '•'

Page2 ' ·•

agreement with the findings of Officer Brailsford's attending physician, that Officer Brailsford's condition was incurred in the performance of his duty, that his condition totally and permanently prevents him from performing a reasonable range of duties within his job classification, arld that any conflicts in the medical evidence have been resolved by the Local Board. He added that in view of the absence of questions from the Board, he would entertain a motion relative to this case.

~ . ' It was moved by Boardmember Russell, seconded by Boardmember Lentz, that the Acctdental Disability Retirement application of Police Officer Philip Brailsford be approved.

Upon tabulation of votes, it showed:

A YES - Brady-Lentz-Raines-Russell NAYS- None ABSENT - Jones

Chairman Raines declared the motion carried unanimously by those present.

Chairman Raines thanked Police Officer Philip Brailsford for his service to the City.

2. Adjournment.

Without objection, the meeting of the Local Police Pension Board adjourned at 10:27 a.m.

I hereby certify that the foregoing minutes are a true and correct copy of the minutes of the Public Safety Local Police Pension Board meeting of Mesa, Arizona, held on the 81h day of October, 2018. I further certify that the meeting was duly called and held and that a quorum was present.

vw DEE ANN MICKELSEN, CITY CLERK

PRINT Full Name of Employee

Address

PUBLIC SAFETY PERSONNEL RETIREMENT SYSTEM 3010 E. Camelback Rd., Suite 200, Phoenix, AZ 85016

(602) 255-5575 FAX (602) 296-2369 ww.psprs.com

APPLICATION FOR DISABILITY RETIREMENT Completed by Employee

SSN

'P\o\\\...\? M"'~tu.. ~«A,~r~ (oYb· o~~ '80"l.'"t Date of Birth

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FORM P5-EE Page ·1 of 2

08/17

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~ E'~A, A1. 8S"Z.I"l.. 'ft-~o"e>V-~\~~~'-~ U-3 ~C::,t-\A\\..•C:.c.IV\ Home#

Employer Ci of Mesa

Type of Disability (check ONE):

ICell # (4&0) (c,~- 8'\~

~ccidental r Ordinary

IWork#

r Temporary r Catastrophic

Date of Disabling Event or Condition Diagnosis _.:0~\ ,,_/.:._lt=-+/....:1~~~---TI.L-..!-::5:1)~'-------------Nature and Cause of Disabil ity OH\tE;~ 1~\JI:)\...\l~\) <&~~\~(.,

List the physicians, hospitals and clinics who attended or examined your disability and three years prior For add itional h s icians, attach a su lemental a e Company Name Company Name

A -z. c..e,...sn: fctZ.. M ~ \U.~~ L?C.. Physician Physician Physician

1) . f.~E(Z.ET\ A\\..E }\'11-\Le:E:~ K\Tl.f"\\u..tf. z,u,A(t; ~EN G:.A~ Address -:!i'= Address Address

~v ,v& IZ5'-t E S()JffiEW A\lt \ C£~C:0 ~ 'S \~ tN£ City, State, Zip+4 ?~oE"N ~ A'l... og5<>S' I

City, State, Zip+4 Me~ A'- ~5"Z.c"\

City, State, Zip+4 \'\~ A1.... <l. 'S

Phone ygo ~ <o~Y -5{.cl

Phone · (JSL- q'-I'S -'SIOO

Phone tl~\)-o-z.s-- \ tA~

Illness Illness Illness .?\""';;::. "?r.s

For additional biological or legally_ adopted children, attach a sugQiemental page Spouse and/or biological I legally Print Name: Date of Birth Social Security Disabled Child(ren) adopt~d children : (Last, First, Middle) Number Child(ren)? 18-22 yrs in

Yes or No school

~ouse ~11..\~/ c()(Z.INNE £. '='' ~·50 -~ fu lltime?

r Not applicable 10·'2..3~1~' Yes or No

~hild r Not applicable ~\l\f'~, Loc,AtJ ~ - o'3·'ZO -1~14 (orl{ . <jo- lb'tl" tJo No r chi ld

r child

Rev. 08/2017 EMPLOYEE: Copy for your records and send ORIGINAL to your Local Board.

RECEIVED-PSPRS

OCT 3 f 2018

PUBLIC SAFETY PERSONNEL RETIREMENT SYSTEM 3010 E. Camelback Rd. Suite 200, Phoenix, Arizona 85016

PHONE: (602)255-5575 FAX: (602)296-2369 www.psprs.com

FORM P5~EE Page 2 ·of 2

08/17

APPLICATION FOR DISABILITY RETIREMENT Completed by Employee

INITIAL THE FOLLOWING - Authorizations are in effect from the date of this application to 120 days after first receipt of retirement benefits ;;

i) f"«S I authorize and request each physician and person in the medical or related fields, and each hospital, clinic, establishment and place rendering or having in the past rendered to me any medical or related service to allow the Local Board, the office of the Board of Trustees of the' Public Safety Personnel Reti rement System (PSPRS), their authorized designee, and/or each physician appointed by them to have, examine and/or copy, any and all information, records, reports and x-rays, regarding my physical and/or mental condition and treatment therefore.

2) fMfS I authorize the Local Board, the office of the Board of Trustees and/or their authorized designee to procure from my employer(s) or from any other person, firm or corporation (including any governmental agency or department thereof) any and all information as directly related to leave(s) of absence without pay and/or application(s) for and/or receipt of Worker's Compensation Benefits. I expressly waive all provision of law forbidding any physician, person, firm or corporation (including any governmental agency or department thereof) from disclosing any knowledge or information wh ich they have in their possession concerning leave(s) of absence without pay and/or Worker's Compensation.

3) 'Yf"\~ I understand that pursuant to A.R.S . § 38-847{H), the Board of Trustees may perform a review of the disability retirements to ensure that the employee and Local Board are in compliance with statutory requirements.

4) ____ WAIVER OF CONFIDENTIALITY. I hereby consent, upon the advice of counsel, that all matters and issues relating to my physical or mental cond ition or medical history, including, without limitation, whether my physical or mental condition arises from any preexisting disability, may be discussed and considered by the Board of Trustees and/or Local Board in open public meeting, and I hereby waive any right to have my physical or mental condition or medical history discussed and evaluated by the Board of Trustees and/or Local Board in executive session only. As part of the aforesaid waiver, I further consent that the Board of Trustees and/or Local Board may discuss and consider all evidence touch ing upon my physical or mental cond ition or medical history in open public session, including without limitation, testimony or records concerning my physical or mental condition or medical history from physicians or other expert witnesses, the social security administration, the state industrial commission, or other sources or persons of any kind or description . I understand that neither the Board of Trustees nor the Local Board has any obligation to keep confidential any information about my physical or mental condition or medical history that is discussed, presented or considered during any public session of the Board of Trustees or Local Board, and I absolve the Board of Trustees and Local Board from any liability arising from disclosure of such information during public session .

I hereby submit my application for a disability pension subject to all of the terms and conditions of the PSPRS. I attest that all information submitted is true, complete and correct to the best of my knowiedge and belief. I understand that A.R.S. § 38-849(B) states: "A person who knowingly makes any false statement or who falsifies or permits to be falsified any record of the system with an intent to defraud the system is guilty of a class 5 felony."

EMPLOYEE SIGNATURE h~"'---"'----T,c..._-D~~------ DATE __,QLY_,._,_/_,~,_.g-'~/-":uJ=-<-..._1..,.~­PRINTED NAME __:_JA_~_I_I__..:P __ --'-----'...,._.,.::;:_:..........,_._-=-==----

Provide a copy of the applicable documents to your Local Board

1. Birth certificate, Drivers License, or Passport for member 4. Medical documentation for disabled children 2. Recorded Marriage and birth certificate for spouse

3. Dependent ch ild(ren) birth certificates

5. If divorced during period of employment: Divorce Decree, or Certified

Retirees are eli ible for health insurance benefits. Contact your em lo er and/or PSPRS for information.

DATE

Rev. 08/2017 EMPLOYEE: Copy for your records and send ORIGINAL to your Local Board.

RECEIVED-PSPRS

OCT 3 1 2018

PUBLIC SAFETY PERSONNEL RETIREMENT SYSTEM CORRECTIONS OFFICER RETIREMENT PLAN

ELECTED OFFICIALS' RETIREMENT PLAN 3010 East Camelback Road, Suite 200

Phoenix, Arizona 85016-4416 www.psprs.com (602) 255-5575

PSPRS RETURN TO WORK ACKNOWLEDGEMENT

FORM P16 08/17

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To be completed by the employee at the time of retirement (or enter/exit DROP) with an effective retirement date on or after 8/1/2012 •;r

Section 6109 of the Internal Revenue Code mandates disclosure of your Social Security number (SSN). We will only use your SSN to obtain account information and to inform the Internal Revenue Service (IRS) of distributions and withholdings.

SECTION 1 - PRINT Member Information SSN

~4lo- ()~·%Ott. Name(Last)

~eA\\..~~ ott..()

Employer

L\"t't Of HE~A. 1'~\t.E. (First)

SECTION 2- Return to Work Guidelines Pursuant to A.R.S. § 38-849(E)

INITIAL EACH ITEM BELOW

f'Ml, 1. I have received a copy of the A.R.S. § 38-849 as it relates to the return to work guidelines.

Retirement Type {Check One)

QNormal / DROP @Disability

(Middle)

~ I"Hlo\E.LL

~~ 2. At any time I become employed in the same, or substantially similar position, by the employer from which I retired, my retirement benefits (including DROP if applicable} will be suspended and I cannot make additional contributions to the PSPRS or accrue additional service credit. Furthenmore, I understand that the employer will be required to pay an "alternate contribution rate" to the PSPRS (based on my gross salary during the period of reemployment) and I will not receive these contributions or accrue additional service credit based on these contributions when I tenminate my reemployment (§ 38-843.05).

TMg 3. In order for me to continue to receive my pension benefits, I must terminate my employment and be retired for a minimum of one (1) year from the effective date of my retirement before I return to work, in any capacity, by the employer from which I retired. However, if I return to work, in any capacity, by the employer from which I retired before the one (1) year requirement, my retirement benefits will be suspended and I cannot make additional contributions to the PSPRS or accrue additional service credit. In either case, I understand that the employer will be required to pay an "alternate contribution rate" to the PSPRS based on my gross salary during the period of reemployment and I will not receive these contributions or accrue additional service credit based on these contributions when I terminate my reemployment(§ 38-843.05} .

'fto\~ 4. If I subsequently become an elected official by election or appointment, it is not considered reemployed by the same employer and, as such, my benefits will not be suspended .

1'f'4e 5. I can return to work with the employer from which I retired and continue to receive my retirement benefits as long I am retired for a minimum of sixty (60) consecutive days from the effective date of my retirement and was hired as a result of participating in an open, competitive, new-hire process for an entry-level , nonsupervisory position, or I was hired as a fire inspector, or arson investigator.

PI'\~ 6. If I am assigned to voluntary duties (i.e., acting as a limited authority peace officer for an employer pursuant to the Arizona peace officer standards and training board rules), I can continue to receive my retirement benefits.

~~ 7a. If I am receiving a disability retirement (and have not reached normal retirement) and have then become employed by any employer in a PSPRS covered position, my disability retirement benefits will cease and my employer and I will be required to make retirement contributions to the PSPRS based on compensation defined in § 38-842 (12). Upon el igibil ity for retirement, service from the disability retirement will be considered as "service" and not "credited service" and my average monthly compensation will be based on the compensation from the new employment.

"Ptt6 7b. At any time following retirement, if I am awarded an accidental disability, ordinary disabi lity, catastrophic disability, or temporary disabil ity benefit and accept a job reassignment as an accommodation in accordance with the Americans with Disabil ities Act of 1990, due to my disability that is directly related, my retirement benefits will not be suspended.

~B 8. I do not have an implicit, or explicit pre-existing agreement with the employer from which I retired, whether written or verbal, to return to work, in any capacity, after my retirement.

~t 9. If I am reemployed by the employer from which I retired, within ten (1 0) days of reemployment, the employer shall notify the Local Board, in writing, whether I have been reemployed in the same position from which I retired.

f'tf~ 10. The Local Board must make the determination of my return to work eligibility and detail their decision in the Local Board meeting minutes. I understand that if ttw Local Board does not provide the PSPRS with the necessary documentation to review my return to work eligibility, my retirement benefits may be suspended pending PSPRS review.

SECTION 3- My SIGNATURE below acknowledges that I understand the return to work guidelines as stated above:

Date

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If

1/ L-/z ThiS document IS a summary and does not replace statutory provisions, or legislative changes. ;:} i= r E I v E D -p 5 p R ~

If there are any conflicts, the Arizona Revised Statutes, along with Federal codes for the Internal Revenue Service, sh~li'\l~e?ir.'

OCT 3 1 2018

PUBLIC SAFETY PERSONNEL RETIREMENT SYSTEM 3010 E. Camelback Rd., Suite 200, P.hoenix, AZ 85016

(602) 255-5575 FAX (602) 296-2369 ww.psprs.com

FORM P5-LB 081,1"7

Philip Brailsford

LOCAL BOARD DETERMINATION FOR DISABILITY RETIREMENT Completed by Local Board

646-03-8022 PRINT Employee/Member's Name SSN

Based on the "type of disability'' selected by the employee on FORM P5-EE, complete the applicable Disability Questionnaire.

Employer Mesa Police Dept.

Service Date from 7/1/2013 to 03/22/2016

Industrial Leave to

Leaves Without Pay (#of missing pay periods) 4

Work Status D Working Full-time · D Working Part-time

I2S] Not Working D Limited Duty D Unpaid Leave 0 Regular Assignment 0 Paid Leave Other (Select all that apply)

Date employee became unable to perform the duties of his/her PSPRS position? 01/18/2016

'DETERMINATION:

Pursuant to A.R.S. §§ 38-847 and 38-859, the Local Board has detenmined that the employee:

D Does not qualify for a disability retirement.

rn Qualifies for an ACCIDENTAL DISABILITY retirement effective the 1st of (enter month/year):

0 Qualifies for an ORDINARY DISABILITY retirement effective the 1st of (enter month/year):

0 Qualifies for a TEMPORARY DISABILITY retirement effective the 1st of (enter month/year):

November 2018

·.{

;r

0 Qualifies for a CATASTROPHIC DISABILITY retirement effective the 1st of (enter month/year):---------

A.R.S. § 38-845.02 states that "the Board shall not make a retroactive payment of a pension of a person that is more than one hundred eighty days before the date of the person's application for benefits."

-====-=-~-~:-=D::..:e::.::e":'A'::n:'-'n-'-=M7ic:;;k.:::cel""s""en':----;::-:--.,.----~"" ~ 10/08/2018 PRINT Name of Local Board Secretary or Chairman Signature Board Meeting Motion Date

Pursuant to A.R.S. § 38-847(F), the Board of Trustees may perform a review of the disability retirements to ensure that the Employee and Local Board are in compliance with statutory requirements.

LOCAL BOARD INSTRUCTIONS: Return to the PSPRS the ORIGINAL FORM PS-EE and ORIGINAL PS-LB. Provide a copy of the "applicable documents" stated on Form PS-EE, ORIGINAL Disability Questionnaire and a copy of the Medical Examination. It is also required we receive the Local Board meeting minutes via certified mail pursuant to A.R.S. § 38-847.F.

Rev. 08/2016

RECEIVED - PSPRS

NOV 2 1 2018

PUBLIC SAFETY PERSONNEL RETIREMENT SYSTEM 3010 E. Camelback Rd., Suite 200, Phoenix, AZ 85016

(602) 255-5575 FAX (602) 296-2369 ww.psprs.com

FORM:P5-LB 08/17

LOCAL BOARD DETERMINATION FOR DISABILITY RETIREMENT Completed bv Local Board

Philip Brailsford 646-03-8022 PRINT Employee/Member's Name SSN

LOCAL BOARD INSTRUCTIONS: Based on the "type of disability" selected by the employee on FORM P5-EE, complete the applicable Disability Questionnaire.

Employer Mesa Police Dept.

Service Date from 7/1/2013 to

Industrial Leave ---~! ____ ! ___ _ to

Leaves Without Pay (#of missing pay periods)

.. ,

Work Status n Working Full-time D Working Part-time

[")('] Not Working /

0 Regular Assig~ftnt Limited Duty D Unpaid Leave

(Select all that apply) Paid Leave Other

Date employee became unable to perform the duties of his/her PSPRJYP'osition? 01/18/2016

!DETERMINATION~

Pursuant to A.R.S. §§ 38-847 and 38-859, the Local Board has determined that the employee:

0 Does not qualify for a disability retire mer;;.

I2S] Qualifies for an ACCIDENTAL DISd LITY retirement effective the 1st of (enter month/year):

0 Qualifies for an ORDINARY. ISABILITY retirement effective the 1st of (enter month/year):

0 ARY DISABILITY retirement effective the 1st of (enter month/year):

November 2018

0 Qualifies for a TASTROPHIC DISABILITY retirement effective the 1st of (enter month/year):----------

A.R.S. § 38-845.02 s tes that "the Board shall not make a retroactive payment of a pension of a person that is more than one hundred eighty days before the date of the person's application for benefits."

Dee Aoo Miokel,en flet_ ~ 10/08/2018 PRINT Name of Local Board Secretary or Chairman Signature Board Meeting Motion Date

Pursuant to A.R.S. § 38-847(F), the Board of Trustees may perform a review of the disability retirements to ensure that the Employee and Local Board are in compliance with statutory requirements.

LOCAL BOARD INSTRUCTIONS: Return to the PSPRS the ORIGINAL FORM P5-EE and ORIGINAL P5-LB. Provide a copy of the "applicable documents" stated on Form P5-EE, ORIGINAL Disability Questionnaire and a copy of the Medical Examination. It Is also required we receive the Local Board meeting minutes via certified mail pursuant to A.R.S. § 38-847.F.

Rev. 08/201 6

RECEIVED-PSPRS

OCT 3 1 ?01R

City of Mesa PRINT Name of Employer

PUBLIC SAFETY PERSONNEL RETIREMENT SYSTEM 3010 E. Camelback Rd. Suite 200, Phoenix, Arizona 85016

PHONE: (602)255-5575 http:/lwww.psprs.com/

ACCIDENTAL DISABILITY QUESTIONNAIRE Completed by Local and Medical Board (as applicable)

Philip Brailsford PRINT Name of Employee

Pursuant to A.R.S. §§ 38-842(1 ), 38-844 and 38-845, an "Accidental Disability" means a physical or mental condition that the Local Board finds totally and permanently prevents an employee from performing a reasonable range of duties within the employee's job classification and that was incurred in the performance of the employee's duty.

1. Did the employee file the application after the disabling incident, or within one year of ceasing to be an employee?

2. Did (or will) the employee terminate by a reason of disability?

3. Did employment terminate based on a disciplinary issue?

4 If the member's period of DROP has ended, if applicable, did (or will) the employee terminate by a reason of

· disability?"

5 Is the employee still v.orking a position within their job classification that the Local Board considers a reasonable

· range of duties position?

6. Has the employee refused a position within their job classification that the Local Board considered a reasonable range of duties?

7. Did the injury or condition occur prior to the~ PSPRS membership date?

8. Was the injury or condition the result of an event incurred during the performance of the employee's duty?

./ J

J

../

if

FORM PS-LB-A 08/17.

Local Board Response

v: NO ~~

. YES NO

YES J NO

I§ ~ YES ../ 103 YES ../ I® YES J I(NQ) YEs) NO

LOCAL BOARD INSTRUCTIONS: If it is determined that the employee does not qualify, complete FORM P5-LB, provide copy of supporting documents and Local Board meeting minutes to the PSPRS. If the employee may qualify, an independent medical examination (I ME) will need to be performed. Sign/date this questionnaire and forward the ORIGINAL, including copy of all medical evidence, job classification/description, current PSPRS membership date and any additional questions to the Medical Board.

MEDICAL BOARD (PHYSICIAN) INSTRUCTIONS: In addition to an independent medical examination Physician

(I ME report), answer the following questions, sign/date and return the ORIGINAL to the Local Board. Provide additional comments in the IME report.

Response

1. Does the employee have the physical or mental condition that is the basis for the disability application? v YES NO

2. Does the injury or condition totally prevent the employee from performing a reasonable range of duties within the employee's job classification? To the extent possible, explain in the IME report those duties the employee's injury vi YES NO or condition would totally prevent the employee from performing.

3. Does the injury or condition permanently prevent the employee from performing a reasonable range of duties

I within the employee's job classification? To the extent possible, explain in the IME report those duties the YES NO employee's injury or condition would permanently prevent the employee from performing.

4. Was the injury or condition the result of an event incurred during the performance of the employee's duty? v YES NO

5. During your examination of all medical evidence, did you discover any pre-existing conditions or injuries that

/ contributed to the claimed disability? If yes, please explain in the IME report. ("Pre-existing" is defined as occurring YES NO prior to the employee's current PSPRS membership date.)

6. Are there conflicts in the medical evidence? If yes, please explain in the IME report. YES v NO

LOCAL BOARD: If conflicts in the medical evidence, address if and how they were resolved in the Local Board meeting minutes. LOCAL BOARD AND PHYSICIAN: By the signature below, 1/we attest that the medical records have been thoroughly reviewed, each section has been answered by the appropriate party indicated above, and the information contained herein is true, complete and correct to the best of my/our knowledge and belief.

" PRINT Name of Local Board Secretary or Chairman S~AA ~L]J~ Dat7 Dee Ann Mickelsen 0-0~- 1~

PRINT Physician Name and Title (e.g. , M.D.) Sign~ Date/O-<-/-Ig' Lisa S. Jones, MD

'"' Rev. 08/2017

~

RECEIVED-PSPRS

OCT 3 1 2018

··,

.. .. DISABILITY RETIREMENT APPLICATION ACKNOWLEDGEMENT

.,

Please initial each statement acknowledging to the City of Mesa and the Public Safety Perso"finel Retirement System (PSPRS) Local Board that you have received and understand the following:

DATE

I understand that my department will be notified of my application status at the time· my application is received.

My current duty status is (mark all that apply): o Working Full-time o Working Part-time o Not Working o Regular Assignment o Unpaid Leave o Paid Leave

o Modified (Limited) Duty o Other ------

I understand that medical documentation relevant to my disabling injury/injuries will be obtained from the City of Mesa Workers Compensation Office. I have been advised that the City Clerk and Senior Program Assistant will review my medical records and that I will have the opportunity to review the documents and receive a copy prior to the first Local Board meeting.

I understand that if I have been divorced while a member of PSPRS I am required to submit a certified divorce decree(s) (whether or not they affect my benefit payments) to the PSPRS legal department before any pension benefit will be paid.

I understand that the disability application process takes a minimum of two (2) months and two (2) Local Board meetings. The first meeting will allow the Local Board to review the medical documentation relevant to my medical disability and it's effect on my ability to perform my job. If appropriate, the Local Board will refer me to a Board Physician for an independent medical evaluation (IME). The second meeting will be held in order for the Local Board to review the IME report and decide my eligibility for a disability retirement.

I understand that it may be necessary for me to be present either in person or by phone at both Local Board meetings in order to address any questions the Local Board may have and that failure to attend may cause a delay in my application process.

I understand that although my initial application requires my signature, it will be necessary for me to be available after my last day of employment to sign my final retirement application paperwork in order to receive my first retirement check at the end of the month that my retirement becomes effective. In the event my application is denied, if eligible for normal retirement, I may apply for normal retirement that same date or the City will process my resignation.

RECEIVED-PSPRS

OCT 3 1 2018

i:\psafety\application packets\mesa forms\acknowledgements and waivers\acknowledgement.disability ret.doc

Robert Ortega

From: Joann Lowey Sent: To:

Tuesday, July 09, 2019 12:40 PM Robert Ortega

Subject: Attachments:

FW: Disability- Brailsford, Philip Reinstatement

Joann Lowey Retired Members Team Leader Phone (602) 255-5575 X2002 Benefits Fax (602) 296-2369

From: Joann Lowey Sent: Tuesday, November 13, 2018 9:53 AM To: Bonnie Brown <bonnie@psprs.com>; Michelle Pechan <mpechan@psprs.com>; Robert Ortega <rortega@ psprs.com> Subject: FW: Disability- Brailsford, Philip

FYI - - from DeeAnn regarding Brailsford - - Thank you - Joann

Joann Lowey Retired Members Team Leader Phone (602) 255-5575 X2002 Benefits Fax (602) 296-2369

From: DeeAnn Mickelsen [mailto:Dee.Ann.Mickelsen@mesaaz.gov] Sent: Tuesday, November 13, 2018 9:46AM To: Joann Lowey <joann.lowey@psprs.com>; Vanessa Wisneski <Vanessa.Wisneski@mesaaz.gov> Cc: Holly Nelson <Holly.Nelson@MesaAZ.gov>; Alfred Smith <Aifred.Smith@mesaaz.gov> Subject: RE: Disability- Brailsford, Philip

Joann,

The local board has been notified of the issue related to the retirement date, reinstatement, and enrollment form (see attached).

Let me know if there is anything else we need to do to resolve the issue with this retirement application.

Thanks,

Dee Ann Mickelsen, MMC City Clerk City of Mesa Office of the City Clerk P: (480) 644-6987

1

F: (480) 644-2821

The City of Mesa's business hours are 7:00A.M.- 6:00P.M. Monday- Thursday and closed on Fridays.

From: Joann Lowey <joann.lowey@psprs.com> Sent: Monday, November OS, 2018 3:S4 PM To: Vanessa Wisneski <Vanessa.Wisneski@mesaaz.gov> Cc: DeeAnn Mickelsen <Dee.Ann.Mickelsen@mesaaz.gov>; Holly Nelson <Holly.Nelson@MesaAZ.gov>; Alfred Smith <Alfred .Smith@ mesaaz.gov> Subject: RE: Disability- Brailsford, Philip

Hi Vanessa--

We reviewed the information with the Member Services Director, Robert Ortega, and he has requested that the local board be notified in writing about the issue with the member's service. Until the service issue is resolved we are not able to move forward with the disability review.

Thank you - Joann

Joann Lowey Retired Members Team Leader Phone (602) 255-5575 X2002 Benefits Fax (602) 296-2369

From: Vanessa Wisneski [mailto:Vanessa.Wisneski@mesaaz.gov] Sent: Monday, November OS, 2018 3:23 PM To: Joann Lowey <joann.lowey@psprs.com> Cc: DeeAnn Mickelsen <Dee.Ann.Mickelsen@mesaaz.gov>; Holly Nelson <Holly.Nelson@MesaAZ.gov>; Alfred Smith <Alfred .Smith@ mesaaz.gov> Subject: RE: Disability - Brailsford, Philip

Hi Joann,

We just met with HR and Payroll regarding this. The HR department is working on the membership form and will get that submitted as soon as possible.

Does the form need to be in by Nov. 10t h in order for Mr. Brailsford to be paid his first pension check on time?

From: Joann Lowey <joann.lowey@psprs.com> Sent: Monday, November OS, 2018 8:47AM To: Vanessa Wisneski <Vanessa .Wisneski@mesaaz.gov> Subject: RE : Disability - Brailsford, Philip

Hi Vanessa --

2

Thank you-- The member's record does not indicate that it was reinstated. So I was just asking the Active Department about it because I am looking for the member's file here.

The Active Department indicated that there should be a Membership Form completed.

Let me know what you find out there and I am working with the Active Department here.

Thank you - Joann

Joann Lowey Retired Members T earn Leader Phone (602) 255-5575 X2002 Benefits Fax (602) 296-2369

From: Vanessa Wisneski [mailto:Vanessa.Wisneski@mesaaz.gov] Sent: Monday, November OS, 2018 8:23 AM To: Joann Lowey <joann.lowey@psprs.com> Subject: RE: Disability- Brailsford, Philip

Hi Joann,

I think our HR department should have updated the PSPRS system with the reinstatement date in August, but did not. I have contacted HR about it.

Senior Program Assistant, Office of the City Clerk Phone: 480-644-5293 Fax:480-644-2821

o(III''!J'~~mesa ·az

From: Joann Lowey <joann .lowey@psprs.com> Sent: Friday, November 02, 2018 5:07 PM To: DeeAnn Mickelsen <Dee.Ann.Mickelsen@mesaaz.gov>; Vanessa Wisneski <Vanessa.Wisneski@mesaaz.gov> Subject: Disability- Brailsford, Philip

Hello - -

We received the disability documents for Philip Brailsford, however, the member's record has a Termination Date of 03/22/2016 so the member had one year from date of termination to make application for the disability.

The application indicates that he made application 08/28/2018- over 2 years after the date of termination.

And we will need the local board minutes where the disability was discussed and how/why the local board decided to award the disability.

Thank you - Joann

3

Joann Lowey Retired Members T earn Leader Phone (602) 255-5575 X2002 Benefits Fax (602) 296-2369

4

Joann Lowey

From: Sent: To: Cc: Subject:

Joann Lowey Wednesday, November 14, 2018 4:57PM 'Vanessa Wisneski'; DeeAnn Mickelsen Bonnie Brown; Tara Davis Disability- Philip Brailsford

Hi Vanessa & DeeAnn - -

.,. •f:

:·

.,

The Tier 2 spreadsheet will need to be adjusted for the calculation to correctly calculate the Average Monthly Compensation - - Here is what will need to happen - -

The member does not have 60 consecutive months of contributions - he did contribute July 2013 to March 2016 for about 32 months - -The spreadsheet will only calculate the number of months contributed if input in this spot for Current Years of Service.

Jc. AVERAGE MONTHLY COMPENSATION fLINE B /32.724 months}:

Then there are no contributions for the date range 08/27/2018 to 10/08/2018 - which is ( 4) pay periods that are missing - -

-Leaves without Pay

Then we can note the Years of Service for the range 08/27/2018 to 10/08/2018 - -which when input calculates to 0.118 years so we are accounting for that service.

Prior Service - ~ - -

By entering the service in this manner the spreadsheet will calculate the monthly benefit amount using the contributions submitted.

And the member's highest years tot,al salary is $168,149.22-- -I ran the highest years from the Local Board Portal and it will project and duplicate when it should not.

1

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If you have any questions, Bonnie will be here tomorrow ar.u Friday - - I am off until Monday, November 19, 2018.

Joann Lowey Retired Members Team Leader Phone (602) 255-5575 X2002 Benefits Fax (602) 296-2369

2

jr•" ,,

li

Joann Lowey

From: Sent: To: Subject:

Vanessa Wisneski <Vanessa.Wisneski@mesaaz.gov> Wednesday, November 07, 2018 10:32 AM Joann Lowey FW: Reinstatement

From: DeeAnn Mickelsen <Dee.Ann.Mickelsen@mesaaz.gov> Sent: Tuesday, November 06, 2018 2:45 PM

I-~ i·l

·I

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To: 'bgraines@cox.net' <bgraines@cox.net>; 'barbarajones1010@yahoo.com' <barbarajones1010@yahoo.com>; Stephen Lentz <Stephen.Lentz@mesaaz.gov>; Ryan A Russell <Ryan.A.Russell@mesaaz.gov> Cc: Vanessa Wisneski <Vanessa.Wisneski@mesaaz.gov> Subject: Reinstatement

Local Police Pension Board,

PSPRS has requested that the Local Board be notified of a recent issue and steps that have been taken to correct the issue.

The City of Mesa reinstated Police Officer Philip Brailsford on 8/27/2018. While his employment with Mesa was reinstated in our Human Resources Management System (HRM), a new PSPRS membership form was not completed. PSPRS was not aware of the reinstatement until October 31st when they received all paperwork to process his retirement. PSPRS notified us of the problem on November 2nd.

To correct this problem, a new membership form for Officer Brailsford was completed and routed to PSPRS today. At the request of the PSPRS Member Services Director, Robert Ortega, we are notifying you of this issue.

Thanks,

Dee Ann Mickelsen, MMC City Clerk City of Mesa Office of the City Clerk P: (480) 644-6987 F: (480) 644-2821

The City of Mesa's business hours are 7:00A.M. - 6:00 P.M. Monday- Thursday and closed on Fridays.

To ensure compliance with tlze Open Meeting Law, recipients oft/tis message should not forward it to other local boardmembers. Members of tlte public body may reply to this message, but they should not send a copy of the reply to other boardmembers.

1

Joann Lowey

From: Sent: To: Subject:

Vanessa Wisneski <Vanessa.Wisneski@mesaaz.gov> Wednesday, November 07, 2018 10:34 AM Joann Lowey FW: Reinstatement

Boardmember Chris Brady was notified through his Executive Assistant Tammy Miller.

From: DeeAnn Mickelsen <Dee.Ann.Mickelsen@mesaaz.gov> Sent: Tuesday, November 06, 2018 2:47 PM To: Tammy Miller <Tammy.Miller@mesaaz.gov> Cc: Vanessa Wisneski <Vanessa.Wisneski@mesaaz.gov> Subject: Reinstatement

Tammy,

·.t .. .. ,

..

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I have sent the email below to the Local Police Board Members. Can you please provide Chris with this information as well.

Local Police Pension Board,

PSPRS has requested that the Local Board be notified of a recent issue and steps that have been taken to correct the issue.

The City of Mesa reinstated Police Officer Philip Brailsford on 8/27/2018. While his employment with Mesa was reinstated in our Human Resources Management System (HRM), a new PSPRS membership form was not completed. PSPRS was not aware of the reinstatement until October 31st when they received all paperwork to process his retirement. PSPRS notified us of the problem on November 2"d.

To correct this problem, a new membership form for Officer Brailsford was completed and routed to PSPRS today. At the request of the PSPRS Member Services Director, Robert Ortega, we are notifying you of this issue.

Thanks,

Dee Ann Mickelsen, M MC City Clerk City of Mesa Office of the City Clerk P: (480) 644-6987 F: (480) 644-2821

The City of Mesa's business hours are 7:00A.M. - 6:00 P.M. Monday -Thursday and closed on Fridays.

To ensure compliance witlz the Open Meeting Law, recipients of this message should Jtotforward it to other local boardmembers. Members of the public body may reply to this message, but they should not send a copy of the reply to other boanlmembers.

1