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EMPLOYEES PENSION TRUST FUND OF THE VILLAGE OF TEQUESTA
ENROLLMENT AND BENEFICIARY DESIGNATION FORM •
I, Lori Mon LLB., do hereby request to participate in the Employees Pension Trust
Fund of the Village of Te esta 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 pro ' ions 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 0
Name of Participant: LOri Mon jn q LA—e—;
Address: (Da iO )C Dft •
(-�nl I L tic DI FL- 33C0 `-�
Date of Birth: 3-- I I —l.p —1 Date of Employment: UJ-15`q
1 •
Primary Beneficiary: GC)M10(\ fl '1 1.41°Relationship:
Address:
LDa 7O 5cf) Q f
Ilutw3 & FL 33 �-
Contingent Beneficiary(ies) I. Tv-Acayt
Address: (Pal
C; ^1-,N •
Sc
The right is reserved to revoke this •esignation and subject to due notice to the Trustee to designate
• a new beneficiary. /
!� -I -� •'�' I NIAA un,.. titcd
(Date Signed) (Signature of Participant) (SSN)
(Date Witnessed) (Signature of Witness:Plan offil
or Notary Public)
•
•
08/09/96
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