HomeMy WebLinkAboutDocumentation_Pension General_Tab 4A4_12/15/1997 •
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EMPLOYEES PENSION TRUST FUND OF THE VILLAGE OF TEQUESTA
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
I, 0.V`.r€., Y'\aaci n® 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.
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: q�` a a,w
Address: cc J(OS 5 L ''cox.
Date of Birth: I z-1 31 l t2y Date of Employment: It Al
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Primary Beneficiary: tiVI.ct\-f✓) if\c oe f\a r e Relationship: Li �-e_
Address: COLS- Si- R.Vesr'Ctbn� "Ter.
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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_
/!-(V-97 1.3a1-L LI-$ rl l
(Date Signed) (Signature of Participant) (SSN)
/1-0l-77 Ak Gz-ee�.
(Date Witnessed) (Signature f Witness:Plan official
or Notary Public)
08/09/96
+414), STEMJ ALLI0114
4� �•,"`.�'? MY�AA�MI3910N/CC 673341
E PIR E$:July 30,2000
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