HomeMy WebLinkAboutDocumentation_Pension General_Tab 4B_12/15/1997 •
EMPLOYEES PENSION TRUST FUND OF THE VILLAGE OF TEQUESTA
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
I, hfj v )() / h V! ( ,1do 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 )1 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: c y`j�)�i��/I 7 7 C () 47)
Address: �..c.i r d( i1 i�'f�f C c 0 Or
Date of Birth: ?.)/ 0 ti
Date of Employment: c/i ��
,ff1
Primary Beneficiary: 1TJl)'/9 f/90l'/71CRelationship: (A)i
Address: 1O- 6 x)
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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.
(Date Signed) (Signature of Participant)"a "'--- (SSN)
/o?-10-$7 .!
(Date Witnessed) (Signature Witness:Plan official
or Notary Public)
., . 08/09/96
ok !PN N J.ALLISON K
. MY COMMISSION/I CC 573541 r.
'� EXPIRES:July 30,2000 �j
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