HomeMy WebLinkAboutDocumentation_Pension General_Tab 4A3_12/15/1997 EMPLOYEES PENSION TRUST FUND OF THE VILLAGE OF TEQUESTA
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
I, ILA IC Ff-EL.Le FA LASS- , 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.
j� 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: isk1Ghe.d I. FAlc,z
Address: r315 atop&I }-Flit "$%w •
n-krn Bd/ .) F L 334-35
Date of Birth: 41 12417- Date of Employment: 101151 Rr
Primary Beneficiary: SUSAt4 FALA52. Relationship: 1.AGTHE.
Address: 8 IS CA4 PEL 4+1 LL(3)L\I17.
c 4tJ1b�r{� •} (. 339-35
Contingent Beneficiary(ies) 514-A1Z01•1 9
Address: q2'1 S. W • 351'4. cr,
F L 334-35
The right is reserved to revoke this designation and subject to due notice to the Trustee to designate
a new beneficiary.
1D1201g1 592-44-3120
(Date Signed) (Si attire of Participant) (SSN)
/O-40-5? �•—�} Q�Q,t,
(Date Witnessed) (Signatui4 of Witness: Plan official
or Notary Public)
08/09/96.
''I' STEPHEN J.ALL19
� f:, Mr COMMISSION r c0573541
EXPIRES:July 30 2000
`%Rf,0' Bonded lieu Navy Public Undeiwdmrs