CCR1990284COMMON COUNCIL - CITY OF MUSKEG0
RESOLUTION #284-90
TO AUTHORIZE THE SIGNING OF A DUTY
DISABILITY APPLICATION
BE IT RESOLVED that the Common Council of the City of Muskego,
upon the recommendation of the Finance Committee, does hereby
authorize the Mayor to sign the Employer's Certification on the
Duty Disability Application for David V. Warhanek, pursuant to
Section 40.65 of the Wisconsin Statutes.
DATED THIS 11th DAY OF December , 199,.
FINANCE COMMITTEE
Ald. Daniel J. Hilt
Ald. Edwin P. Dumke
Ald. Harold L. Sanders
ATTEST :
City Clerk
ljh
12/90
2 .: Department of Employe Trust Funds
Wisconsin Retirement System
P 0. Box 7930
Madison, WIsconsin 53707
DUTY DISABILITY APPLICATION
s 40 65 Wis Stats
Print Name and Address of Enploye or Deceased Employe Below
I Last ttrst Mlae Ma I den 1 Social Security mntms are required to nvintain mmters' .~~ ~
WARHANEK DAVID VICTOR
Street Section 6109 of the Internal Revem2 Code.
accounts ad fir federal tax &poses. Statutory
authority is contained in 5. 40.03. Yis. Stats., and
567 W13332 FENNIMORE.COURT
City State Zip Code County of Residence Social Security Nurtxr
MUSKEGO WISCONSIN 53150 WAUKESHA 393-44-4846
ERployer Birthdate (IlolDayIYr)
MUSKEGO POLICE DEPARTMENT 8/21/45
exist:
I apply for duty disability or death tenfits prrsuant to E. 40.65. Yio. Stnts. The follaring conditions of eligibility
-
1. The applicant is, or deceased employe was, a protective occupation participant as defined in s. 40.02 (48) (c).
2. The employe uas injured uhile performing his or her duty or contracted a disease de to his or her occupation.
3. The disability is likely to be permanent.
6. The disability:
caused the enploye to retire fra his or her job. OR caused a rhtion in pay or position. - OR caused work assigmnt to light duty. OR adversely affected promotional opportunities uithin the service, if state or local enployer rules, ordinances, e policies or written agreements specifically prohibit pramtion because of the disability.
Approved medical docmntaticn is required to support permanent disability, uork-related causation, and the effect on
protective employment. Conplete the enclosed Duty Disability Medical Report, ET-5312.
Names of Physicians Involved
With Your Treatment Address
Mark A. Bauer, M.D. 11035 W. Forest Home Hales Corners, WI 53130
Yisconsin Statutes, s. 943.395. provide criminal penalties for kncuiwly mkiw false and fraublent claim.
I hereby certify that the informatim swlied is trw and accurate to the best of nv krouledge. I rndcrstad that
Date (MolDay/Yr) Telephone No.
Y2S'39pO
EUPLOYER CERTIFICATIOW 1
The employer certifies that the nrploye uas injured uhile performiw his or her dty
or contracted a disease &e to his or her occupation. I
The'mnthly salary as defined in E. 40.02 (4lm) for the above-nd employe was I I
The Last day of earnings as an vlrestricted protective employe for the employer uesluill be
Date (Mo/Day/Yr) Telephon No. Title Signeture of Authorized YRS Emloyer Agent
,2/,2/90 679 - +/ 08 u- &' &e . / v Ply 1 File
Ply 2 AFplicant
Ply 3 Enployer
ET-5311 (REV 8/69) 4