HomeMy WebLinkAboutDocumentation_Pension General_Tab 4A2_12/15/1997 •
EMPLOYEES PENSION TRUST FUND OF THE VILLAGE OF TEQUESTA
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
I; Q.\tmc- `�k�r `�,�rr'o kq 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 provisions of the Plan.
X 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: ' ) %r\e 11 Cr Q\&C
Address: 1 \ Rc X `3- .aQ Rc , P\ pa
Date of Birth:k - ‘52`1c Date of Employment: ( 1:3-i 2 -R1 .
Primary Beneficiary: vrct-e elationship:
Address: 1 alt \ Rczk, '�"QO,c. \d &lna
Contingent Beneficiary (ies)
Address:
•
The right is reserved to revoke this designation and subject to due notice to the Trustee to designate
a new beneficiary.
(Date Signed) (Signature of Participant) (SSN)
/0-/Y-?? 22 .
(Date Witnessed) (Signaature Witness:Plan official
or Notary Public)
08/09/96
e ►" s MyS COiEMPHNSI ON rLCUC S5O73M5
.;
�!raci BONES:July 30,2COo„A .
Bonded Thiu Notary PubNC Underai1. ,