HomeMy WebLinkAboutDocumentation_Pension General_Tab 4C_7/28/1998 •
vii agy quests Lump Sum
E r yees'Pension Trust Fund Benefit Payment Authorization
Payee Data Tax Form Address 0(same ae mailine address)
Address
Mail Check to: £ 'ayee ❑Financial Institution/Direct Deposit
Payee Name(Last,FirsR Middle): Address(Including Apt Number,Box or Route Numbers)
Cables, Mercy
Address City
1223 Chippewa Street
Address(Including Apt Number,Box or Route Numbers)
❑Check if Payee is a beneficiary .
City Reason for Separation of Service
Jupiter FL 33458 Noma'Termination
Social Security Number 0 Normal Retirement
- 0 ray Retirement
Participant Census Information 0 Death Benefit from the Account of
Date of Birth Date of Hire Name: Social Security
11-16-61 1-13-97 ❑Disability Retirement
Date oflEatry 7 Date of 6 lta3ti 97 Se/vice ❑Direct Rollover to IRA
❑Direct Rollover to Qualified Plan
Direct Rollover Participant has elected a D Rollove ,_
Other.
Infotmaticn If yea,answer the following 0 yes
Name of Transferee PLm/IRA ?( h s £ * a r' x
Amount of Rollover -, } `x
tom_ .'} �? 2n. .�d x.
Euaploya Employee:
5 t L y v
Total: • • ` .a b, "
FBO(Name of Participant) . r, , > t .. , - `s �'+
Account Number
€ wt
vM1
Address of Financial Lrstitutian % > K , r _
• r
r a' r'•:•; ! S m ` ' ;'z •s i. .d f s 9"
State • y s a z . s t
3
City Zap Code r'` ;„< ?; : a = • �`;.
x,"s.7 tfi."35 y a i '`sa,rx:4;>,4` r/.efk. w� s •e:
< 4 ; • y-,•'-" l '4a•f F t
•
•
•
...K.•..,r._,_3.,�-::..",.,,,�.,.t,.,_. .. ..u"=� z .c .-: / E , E.. yf ,i. .•i C }c
a..?' 1?F st y ,:k c i'171' M-i1 ue_s� Sc fw .1. .i rL 'Fi1 "y i ;mac wa pt siMP+t'L O YEv.. .., ., _ .e_ , T` OTAL Y ,
SEMPLOYERBeneftS Y.
TAXABLE
$ 0.00 $473.38 $473.38
NON-TAXABLE N/A 0.00 0.00
Total Gross $ p;( $473.38 $473.38
20%Mandatory Withholding or elective
Total(1rrJr Amount
Return of Employee Contributions Only.
•
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.a ''' •''' '11-0 •
ri,,,' .equesta Lump Sum
;14:1-40 Pension Trust Fund Benefit Payment Authorization
Tax Form Address .( me as mailing address .,
Address
•
. • , ,„,
_,,..:1.2.„,x ri .
; ..3 , , L._i Payee Krmancial Institution/Direct Deposit
..---,
• ,-,,-‘e -)"
Middle):
,4.c4m4Firsr. Address(Including Apt Number,Box or Route Numbers)
•
- ,•,-.:-.:1-,
-,11'1'fit'd Chris
City
-•-:::,--t--itr,7...
• % ,.. ITIA-g,,_ nkemul der Rd
' •
c`.-:-.<14-.,••,-
• --- --- ' Apt Number,Box or Route Numbas)
4,'.rtztA-111Wdmg
-,.- •,:.,'":2. 0 Check ifPayee iv a beneficiasy
.--:. Reason for Separation of Service
-," •rr-i';'-'1'''
' eliut Creek FL 33073 0 Normal Taminatiou
Number
Ci Noma'Refinanent
4;111,1:4 ---t•'-o'-""/'-'
tf
,,,,- 0....-
Early Retirement 0,.; st:7" :.,
0 Death Benefit from the Account of einant Census Information
Date°fin= Name: Social Seanity:
1.8--6 6 6-16-95
0 Disability Retirement
# IIII37 Date of SeParatea of Service 0 Direct Rollover to IRA
h.rV •?-110SE
9-7-97 0 Direct Rollover to Qualified Plan
I°Illover Participant has elected a Direct Rollover 0 other:
,,K"4"7.../•--';''''rtriegc't,---- —:-
-_-Irifirmition Ifyes,answer the folbrwingAyes 13 no
..., --,--•, ." -"`,.-•+.!...'",,,,,'"A‘,-,,Vr.
4 , , , ,,, ,, ,,.., ....,,,,,,,..., _,*,,,,:"...e; ,..." ,,,,:," '..„ "::• ' •'-' '......--%;:-',..7:.,,,,Z4f;`;'..-').r.'4:"..,,,P-,,; .
-"'f"'+-:'; :f;i*k ' '',.....''. -e,:','./1,,,'•'..":f..e-',:'''''. '‘.:'' , ' ',r,''.,..1•7:..."-,,Cf.0;',
ia-. -Nana of Transtace
.''‘'''"',..- ,-, . -- • :;•-•",:-..;-,' .; -''.....-.••.-:,.'• " ..•••• ';.-;&-..:-.",-„--, ;.1--,•,'•t••-:.
17andalli.
:-.:., , "••• • .••-- - '. ,,.'17;: ,..----• •- •-'-7;....:;',..'t.5?-:`,-;:,"..,''
. '-' -'•z. ,''''., '' .7:4- ...,• ;-,,,:...:":-:,..".',.':',1-:- -:‘•': ::•"'- ''.-1''-"' .--,:i-' ,",.--;'-`;'••:,,:
Amount of Rollover " q 1 ::•-•,.. -..-:,, .. ,- ,,. ., , ,•,;„ _ ,',..„,.--,..., ,,-,:7,-..f--":;-,:,0,,;:--• .:- ....7tii,'.%-...._a.,,4..4::-5.."--J.V.-.'"-;
: EnIPIOYer: Euiployee4
942, , ,,„...... ..„.;-.',-.'' 1 - - F. **"." • s --. ''T--:-•-:•---;'''-':::','!".3' .'" -.,''..,:.• -...':•-,.,,),"-!: ,
'`. ' . .. : ; ;' • t-= ....;;:-,,.--:- ..".,.--=',-....: ..-', .„, 22_...-,,._,-.,.., , .:,4:..,,„FFID(Name of Participant)
, ---1.'.:- ,:- .., • • - - - ' •• •,••• '.. , -* ,• - - ---; ,..--,,?3 r;:•.1, - , - -: • ":'; , .' *•• ,.'' - :. • . -' - •
t_.:L/ / -7-o yoh‘ke 2 d..e4e.:7
Account Number
:' - ' . - .- . - • "„.'4---'• - .--,".:":"•• '' ,...--' •-- ' ' ' -
7.7 F..- b• •,:,.-.7.,, . ; ..','.2—., , , ,: ,,,, - ‘, :-•';;:::,:. :'1'''','; -„:.,_...-:,-' --,-'•-•••:-
L S ( g 53 ( ,/..i_b 5-1:4)....70r)E--5( r - te. ,..._1,,,.,, ....;_•,.... _,_._-,...,,, ..,.... . ,....,.,..,_,..„,:i.„...;:.,,,,;:-,-.....,-,,t.:-.,,,-;.,...t,..-,:i.:-.„ .;.- 1,.,..,-...,•:.„.,-..,::::-..„,F.,:.....,..:,..„
.
Address ofFinancial Institution :...i.' r.: ' '':''',,.-•': •••S' - "-.,•••:'..:',1'..:'-',•-:•1! =,:l.. 1.",i.."'.'!"•::,', •'.4..d. :',:', ':'''
.e,',‘1"1` •,,,,,..3 -, :-;.:-. .., , -v:e::2?-...:-,1,..:%.:!,,:;,=:;.:',),!..":•., --`' :-.' ''...",-- 1-..:•',..1,,-4..;
-c ,dic ;-›/Q/3° .,-'.- -,,...' . . , 1", ,.. , ,,,,-„,..;.,...•. .,,./..--" , `.7,-t 1.-.:,,,,,,' ..-1.- • . .: ;
City State Zip Code
.---
5Z.,„. ..... --
• • •
- . I'eL•''f,E-i'ts, .;‘-_.;,;' '..::,, .:.4,.-,,:-,-,..-.-.•2
.:,•'Z- -A..2-
,—_-9
., -,,-• l-V.I.P.;:L---'--O,-.y,-,:.,Y...-..•E"--•-E•:,•": ,,;-•,.:.f-',(.,.•f.-'.-:"'-
._-..T.•,...„.k,O..•.r-. .L'•.:.. .
' ''_ 2 .
$0.00 4
"$3,962.41 $3,962.41
-N9N-TAXABLE N/A $ 0.00 $ 0.00
Vital Gross .0.00 %3 962.41 %3 962.41
20,61Wandatory Withholding or elective
-
Toil theck Amount
Ilettern of Employee Contributions Only.
,77/(4).11t
_...0---• e.....
j ar -- Village ofTequesta
,,, LUMP SUM
if"
� o Employees'Pension This!Fund Benefit Payment Authorization
O .0
Payee Data Tax Form Address ❑ (saz,...a■saili
ng address)
Mail Check to: U Payee 0 Financial Institution/Direct Address
Deposit
Payee Name (Last, First, Middle) Address (Including Apt. Number, Box or Route
PAULETTI, BRUCE Numbers)
Address ROAD City
Address (Including Apt. Number, Box or Route Numbers) .
❑• Check if Payee is a beneficiary
cityTEQUESTA, FL 33469 Reason for Separation of Service
Social Security Number 13 Normal Termination
❑ Normal Retirement
❑ Early Retirement
Participant Census Information
Date. of Birth .. . Date of Hire ❑ Death Benefit from the Account of • - .
9-24-71 6-2-97 Name: Social Security:
Date of Entry Date of Separation of Service
❑ Disability Retirement
6-2-97 9-17-97 0 Direct Rollover to IRA
Direct Rollover Participant has elected a Direct Rollover
❑ Direct Rollover to Qualified Plan . •-
Information If yes, answer the following CI Yea MI No 0 Other:
Amount of Rollover AUTHORIZATION SIGNATURES:
Employer: Employee: •
. Total: �- s
FBO (Name of Participant) 4
�
Account Number Finance ec r Daee
Address of Financial Institution £ taey Board of Thu tees Date
w? 6. 609„4. 6-27 -?F.
City State Zip Code
Distribution Information •
BENEFITS EMPLOYER EMPLOYEE TOTAL
Taxable
949.19 149 "47
Non-Taxable
•
Total Gross
20% Mandatory Withholding or •
elective
•
Total Check Amount 349.32 349,32
Fonns.EPIF.6.10.98 0 Finance Department
250 Tequesta Drive
RA jul) GI- . ,s G Suite 303
001 ' Tequesta, FL 33469
t Tel. # 561-575-6205
Fax # 561-575-6203
rc---
Village iy,.._, :testa , Lump Sum
Empl Pension n Trust Fund • Benefit Payment Authorization
Payee Data Tax Form Address O fsame as mailing address)
Address
Mail Check to: Payee El Financial Institation/Direct Deposit ' •
Payee Name(Los��'4Pir Middle): Addn s(Including Apt Number,Box or Route Numbers)
Pieris, Robert
Address City
1509 Sumner Ave
Address(Including Apt Number,Box or Route Numbers)
❑(heck if Payee is a beneficiary
City Reason for Separation of Service
Jupiter FL. 33469 ❑Normal Termination
Social Security Number 0 Normal Retirement
❑Baiy Retirement
Participant Census Information ❑D Benefit from the Account of
Dale ofBirth Date of!fire Name: Social Security
12-31-65 9-13-93 0 Disability Retirement
Date of Entry Date of Sepaiation of Service ❑Direct Rollover to IRA •
9-13-9 3 3-15-98 0 Direct Rollover to Qualified Plan
Direct Rollover Participant has elected a Direct Rollover 0 other:
Information Ifyes,answer the following Oyes ❑no
Name of Traacfaee PIan/IRA 7 P 4 c _ < ,•,
.• i 3•ti :z , ,'i w;`rtaK ',zsf-- ". :'te, i •
3 .. .r `4. t 0 ,,L
i, R q • r a.r ar ` ! s.Amount of Rollover a b M ` $- a;Employes: ' • { rfffRwpoyrr Total:
FBO(Name of Participant) # z
e e _lEv.
-
Account Numbs •
.
.ec of P •. •. y i:. J„
•
Address of Financial Institution f
� r �
.
h.;" ' S , .�} y n.•9 SAY. C 7 4+a. ,, 4 +Y' 1
City State lap Code T
.. ...... t
f Ypi tp '11'T lg `{ :si` ki� �;p� n i i', s.. a s.. f-y � de4 ra. ...
Benefits EMPLOYER EMPLOYEE TOTALS
TB $ 0.00 �'6 736.24 $6,736.24
NON-TAXABLE N/A $ 0.00 $ 0.00
$6 736.24
Total Grose $ 0.00 $6,736.24
20%Mandatory Withholding or elective
Total Check Amount
Return of Employee Contributions Only.
•
• -. r
• 0llage of Tequesta • ..- Lump Sum
Em 1 to ees'Pe,Iona Trust Fund Benefit Pa ,rent Authorization
Pa eeData Tax F1rmAc
Address •
Marl Check to ❑Payee ►" mancial Institution/Direct Deposit
•
Payee Name(Las$Fnst,Middle): Address(Including Apt Number,Box or Route Numbers)
Thomas, Michelle ,
Address • • City.
5188 Pine Abbey Drive S
Address Qnduding Apt Number,Box or Route Numbers)
❑Check ifPayeeisabeneficiary .
City Reason for Separation of Service
- West Palm Beach FL 33415 ONannalTenninatioat .
Social Security Number 0 Normal Retires
• ❑Bady Retirement
Partici.ant Census Information O'Dea&Bit from the Account of
Date ofBirth Date of Kite Name: Social Security:
6-27-70 • 5-1-97 • ❑Disability Retirement
,. Date fEn Date o S Servw 0 Direct Rollover o IRA
98
.O Direct Roltovrrto Qualified Plan
Dist Rollover Participant has elected a Direct Rollover O ortns
Information Ifyq answer the following Oyes ❑no .
•
Name of Transferee PImIIRA ,
Amount of Rollover
Employer. Em __. . - _ _
,9
FBO(Name of Participant) •
•
Account Number • V
•
Address ofFinancial Institution
City State Zip Code
•
•
Benefits EMPLOYER EMPLOYEE • TOTALS
TAXABLE $0.00 1 164.9% 4
NON-TAXABLE N/A $ 0.00
$ 0.00
Total Gross $0.00 1 16, 9, , 164 .94
20%Mandatory Withholding or elective
Total Check Amount
Return of Employee Contributions Oiely.
Village oesta Lump Sum
Emp o 'Pension Trust Fund Benefit Pa inept Authorization
Payee Data . Tax Form Addressa as mailingaddress)
K
Address
Mail(arecic to: ❑Payee Financial Institution/Direct DepositPayee Name(!art,First,Midd!e): r Address(Including Apt Number,Box or Route Numbers)
West, Jennifer
Address City -
9185 Balsam Drive
Address(Including Apt Number,Box or Route Numbers)
❑Check if Payee is a beneficiary
City 'Reason for Separation of Service
Lake Park FL 33403
❑Normal Tin
Social Security Number D Normal Retirement
D Early Redremad
Participant Census Information. . ❑Death Benefit from the Account of
Date of Bidh Date of Fine Name: Sacral Security,
8-6-58 8-12-96 ❑Disability Retiranent
Date of Entry Date of Separation of Service Cl Direct Rol overto IRA
•
8-12-96 4-17-98
D Direct Rollover to Qualified Plan
Direct Rollover Participant has elected a Direct Rollover D Other.
Information ryes,answer the following yes ❑no
Name of Transferee Plan/IRA
'i;St 1 f 'Zxi ; _
•
/,i,ip , fEs
Amount of Rollover
—er v ^ Tab Tee- •V V z y •• t
FBO(Name of Participant) - + • • x
/fJ/,��/-".G.Cr ^' „
Account Number :
B:
Address of Financial Institution `x'^
r>26/ ,Co e4 S5 P4.004)4y
City State I Zip Code
f
. —
• ,/ L.1 i W1&h75 ,_ - 6 ..!_: •
� 1S _
._.s ., i
Benefits EMPLOYER EMPLOYEE TOTALS
TAXABLE $ 0.00 $2,245.64 $2,245.64
NON-TAXABLE N/A $ 0.00 $ 0.00
Total Gross $ 0.00 $2,245.64 $2,245.64
20%Mandatory Withholding or elective
Total Check Amount
Return ofEmployee Contributions Only.