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HomeMy WebLinkAboutDocumentation_Pension General_Tab 4A2_7/29/1998 :t3 A---2- • EMPLOYEES PENSION TRUST.FUND OF THE VILLAGE OF TEQUESTA ENROLLMENT AND BENEFICIARY DESIGNATION FORM I, 7ndd t7. Lynch , 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 )C. 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: Toad q. Lyr ck Address: 13o 55 a Q[ c-r- lav°,e,, rr_L 33 3�g Date of Birth: Col CP J 7/ Date of Employment: 4/ 30 /98 Primary Beneficiary: -bck rI a \-)/►i CY\ Relationship: 1A9 1 ce_ Address: l 3 O 5 a S W 9 c r- o; e 1 Ft- 333.25 Contingent Beneficiary (ies) 'Tre.'O( L rt Address: 6$a S • W. Q CT ttiv;�- Fc. 333a5 The right is reserved to revoke this designation and subject to due notice to the Trustee to designate a new beneficiary. VGZ l�6L (Date Signed) (S gnature of Parti nt) (SSN) 7- ( — l (Date Witnessed) _ (Signature of Witness:Plan offici or Notary Public) 08/09/96