1979-20 _= RESOLUTION NO. 79-20
RESOLUTION OF THE CITY COUNCIL OF THE CITY
OF GRAND TERRACE, CALIFORNIA, APPROVING,
AUTHORIZING AND DIRECTING THE FILING OF
AN APPLICATION FOR ELECTIVE COVERAGE OF
DISABILITY INSURANCE
NOW, THEREFORE, the City Council of the City of Grand Terrace does
hereby RESOLVE, DETERMINE AND ORDER as follows:
Section 1 . That the City Manager is hereby authorized and directed
to file an application for elective coverage of disability insurance with
the State of California, Employment Development Department, said applica-
tion to include coverage for the current City employees as shown on the
application attached hereto and incorporated herein, marked as Exhibit "A" .
Section 2. That said application is hereby approved.
Section 3. That the City Manager is hereby authorized and directed
to take any and all actions necessary to implement the purposes of this
Resolution.
ADOPTED this 3rd day of May, 1979.
Mayo of the City of Grand Terrace
and of the City Council thereof.
ATTEST:
96NM�
City Clerk f the City of Grand
Terrace and of the City Council
thereof. Approved as to form:
(_SEAL. S; _ City Attorney
STATE OF CALIFORNIA )
COUNTY OF SAN BERNARDINO ) ss .
CITY OF GRAND TERRACE )
I, SETH ARMSTEAD, City Clerk of the City of Grand Terrace,
DO HEREBY CERTIFY that the foregoing resolution was duly adopted
by the City Council of said City at the regular meeting of the
City Council held on the 3rd day of May, 1979 , and that it was
so adopted by the following vote:
AYES • Councilmen Tillinghast, Erway, Allen, Grant;
Mayor Petta.
NOES : NONE
ABSENT: NONE
City Clerk of the City of Grand
Terrace -and of the City Council
thereof.
STATE OF CALIFORNIA )
COUNTY OF SAN BERNARDINO ') ss.
CITY OF GRAND TERRACE
I, SETH ARMSTEAD, City Clerk of the City of Grand Terrace,
DO HEREBY CERTIFY that the above and foregoing is a full, true
and correct copy of Resolution No. 79-20 of said City Council,
and that the same has not bee-ri amended or repealed.
DATED: May 3 , 1979 .
City Clerk. of the City of Grand
-� Terrace and of the City Council
=- thereof
STATE OF-CALIFORNIA
tMPLOYMENT DEVELOPMENT DEPARTMENT
APPLICATION FOR ELECTIVE COVERAGE OF DISABILITY INSURANCE ONLY
GOVERNMENT ENTITIES
FOR DEPARTMENT USE ONLY
Reference: California Unemployment Insurance Code Section 709 EMPLOYER ACCOUNT NUMBER STATISTICAL CODE
IMPORTANT EFFECTIVE DATE DATE EMPLOYER NOTIFIED
Do not complete this form unless you wish to apply for Disability CLASSIFIED BY DATE CLASSIFIED
Insurance only under Section 709 for ALL of your employees. Coverage
under this section of the Code does not make provision for Unemployment
SEND NUMBER OF EMPLOYEES
Insurance Benefits.
PLEASE TYPE OR PRINT
1. NAME OF GOVERNMENT ENTITY BUSINESS TELEPHONE
CITY OF GRANDTERRACE 824-7226
2. BUSINESS ADDRESS (NUMBER, STREET, CITY, COUNTY, STATE, ZIP CODE)
22140 BARTON ROAD, GRAND TERRACE , CALIFORNIA 92324
3. MAILING ADDRESS (NUMBER,STREET, CITY, COUNTY, STATE, ZIP CODE)
SAME
4. TYPE OF LOCAL PUBLIC ENTITY
E] County LT City F] Other (Specify)
5. Law under which agency was established: (Complete a, b, c, or d)
TITLE OF ACT NUMBER DATE
a. California Tax Law
TITLE OF CODE DIVISION Title CHAPTER
b. California Codes Government Code 1-5 4
TITLE OF CHARTER DATE
c. Charter
TITLE OF ORDINANCE DATE
d. Ordinance
6. Members of governing body of Local Public Entity, such as Board of Supervisors, City Council, District Board of Directors, etc.
NAME TITLE RESIDENCE ADDRESS TELEPHONE SSA NUMBER
Grand Terrace
Tony Petta Mayor 12108 Preston Calif. 92324 783-0658 350-18-1-22;
Mayor GranZ errace
Thomas A. Tillinghasi. Pro-Tem 22667 Brentwood Calif. 92324 825-5351 572-64-237,
Grand lerrace
Douglas Erway Councilman 22585 Kentfield Calif. 92324 783-0149 100-18-243.
Jack en ounce man 11868 Arliss Dr. G . T( Ca . 92321 )825-1308 323-05-655"
Hugh rant"Counci I man - 22560 Eton Dr. - G . T . Ca . 9232 783- 1067- 562-44-37D
NOTE: -If your application is approved, the elective coverage agreement will be subject to all of the requirements and conditions outlined
in form DE 1378L 'Information Concerning Elective Coverage Under Section 709 of the Unemployment Insurance Code.'
Please retain your copy of form DE 1378L for reference.
7• Elected Officers and Appointees (List all elected officers and appointees who pdrform services for the agency named in Item 1.
Exclude persons listed in Item 7.)
7a. Elected Officers (These persons are not eligible for coverage unless the employer elects to cover them for Unemployment Insurance.
Do not include persons listed in Item 7.)
TITLE OF POSITION TITLE OF POSITION
DE 1378M (3/78)
7b. Appointive Positions: (These persons are eligible for coverage unless appointed by the Governor).
NUMBER OF POSITIONS NUMBER OF PERSONS
TITLE OF POSITION IN THIS CATEGORY BY WHOM APPOINTED DESIRING COVERAGE
City Manager - 1- City Council -1-
Administrative
;.ryicPs Officer -1- City Manager -1-
Executive Secretary =1- City Manager -1-
Clerk-Typist - 1- City Manager -1-
Business License Clerk - 1- City Manager -1-
7c. Total number of employees to be covered, excluding
elected officers and those appointed by the Governor -5- .
8. Date on which you wish coverage to be come effective 1 2-1-7 8
NOTE: Deductions should not be made from your employee's wages for the purpose of paying employee contributions required under
the Code until your election is effective.
Attach a copy of the resolution in which.the governing body described in Item 6 approved the filing of an application for elective
coverage under Section 709 of the Unemployment Insurance Code.
The governmental entity described in Item 1 hereby files its application under Section 709 of the Unemployment Insurance Code
to become an employer subject to the Code. It is understood that upon approval of the election by the Director, the governmental
entity will be an employer subject to the Code for Disability Insurance purposes only to the same extent as other employers as
of the date specified in the approval, and will remain a subject employer for at least two complete calendar years. Thereafter,
--this election may be terminated as provided by the Code.
certify that this application has been examined by me, and to the best of my knowledge and belief, it is true and correct and
made in good faith under the provisions of the California Unemployment Insurance Code.
This certificate must be signed by one or more of the persons under Item 5.
SIGNATURE TITLE DATE
"� MAYOR