HomeMy WebLinkAboutDocumentation_Pension General_Tab 4A1_12/15/1997 11
EMPLOYEES PENSION TRUST FUND OF THE VILLAGE OF TEQUESTA
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
I, itfiehek L.M# , do hereby request to participate in the Employees Pension Trust
Fund of the Village of Tequesta on the date as of which I am eligible to begin participation under the
terms of the Plan. I understand the general provisions of the Plan as provided to me and agree to
the ns of the Plan.
prog general employee firefighter police officer
In the event of my death prior to termination of employment, I hereby designate the following
Beneficiary(ies) to receive my death benefit from the Plan
Name of Participant: "Mal 1 " 4
Address: 40105 L1/tz Li E_ L '
jltio/ FL 33q:
Date of Birth: Os-i' alDate of Employment: 68'04 q 7
PrimaryBeneficiary:
�Y C�22,e.e Relationship: hane--14-:*----"
Address: 90S WCCS-1dfl41)p
JiAp le/ FL mire
Contingent Beneficiary(ies) Lia t W /i" !
Address: P911 514) 4 p rtc)1- Ed.
T 5 L FL 3Ljg53
The right is reserved to revoke this designation and subject to due notice to the Trustee to designate
a new beneficiary.
Og-OtPCn igtdahZ Ag461_, 017 7445
(Date Signed) (Signature of Participant) (SSN)
D A4-a,c-g7 (�p�,
(Date Witnessed) (Si atur�f Witness: Plan official
or Notary Public)
08/09/96
to STIPHEN J.MASON —I!
1.1 :;"I MY COMMISSION N cc 57301
16
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