HomeMy WebLinkAboutDocumentation_Pension General_Tab 4A1_7/29/1998 EMPLOYEES PENSION TRUST FUND OF THE VILLAGE OF TEQUESTA
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
I, —Fa(GEC CY v/ ( f I SCA , 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: -Tra ct y T. Fr s 4'A -
Address: I I S /4 Oil)/ '1 "
S I` eef—
L- 1 IC t 11�vvfirl, �L 33�l l� v
Date of Birth: `" I.ZD Date of Employment: 41- t "61 g
Primary Beneficiary: S I I0[1-bNict Sriu[-FISq elationship• u 9 witir
Address: I I 1 5 N o V1Yl ' Y.e S j C
tiA166 V3O ITh r ft, 33U(n 1)
Contingent Beneficiary (ies) i YCC \ L Eh i(6,
Address: pto g r1 NIIrd
W611)1r l(1 Pt, 33141 ti
The right is reserved to revoke this designation and subject to due notice to tile Trustee to designate
a new beneficiary.
11016i8 1 14i 41A-6-
(Date Signed) (Signature la Participant) (SSN)
(Date Witnessed) (Signature of Witness:Plan official
or Notary Public)
•
08/09/96