HomeMy WebLinkAboutDocumentation_Pension Public Safety_Tab 06_02/04/2008•
VILLAGE OF TEQUESTA
PUBLIC SAFETY OFFICERS'
PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
C
PLEASE CHECK WHICHEVER APPLIES TO YOU:
Police Department Employee ~ ~.~' ire Department Employee
I, ~ kLay; ~vr1~ {-~~~'~~;1~'l - do hereby request to participate in the Public
--~~~
Safe O ers',Pension Trust rund 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.
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: ~r~~~y'~rsf %<',; r
Address: ~ - k~t,~,~',.~J
~' ~ ~ ' _~
Date of Birth: ~ ~ - Date of Employment: - ~~ ~' ~- e'~,' --~ ,
Prima Beneficia r ` , !'- -
~' rY~~ ~ c~ ,~ ~..: ~~ ~~~~./
Address., ~~~ i~!'~ic~r_~n.~~K. l_
Relationship: ~,'~~•~~~'`rr.:%~.r"`
r~. .'e1~.:~"~-~~., i~'/~ ~-%~~',~`-~.
-~-
Contin ent Beneficia ~ies ' ,~ (G' • - ~ (< 6,
Address: _f /~' A, ~ ;,~-~ ~'r..i ~! r= 1 y ~~ /'z~ - ~ G-` d°-?, ~= _,°: ~'.,,'~,/ ~-
.c°~
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary.
,<~,. ~ ,r~,~
_ r
atu~ ~'
~~ign ~~ Social Security Number
Date Witnessed
•
Signature of Witness or Plan Official
VILLAGE OF TEQUESTA
PUBLIC SAFETY OFFICERS'
PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
•
PLEASE CHECK WHICHEVER APPLIES TO YOU:
Police Department Employee "~ ~ Fire Department Employee
I, y~~~ ~ - ~„+~.~.~! , do hereby request to participate in the Public
Safety O ers'~Pension Truk rund 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.
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: ,~1FaxiM,E-, A~~ 2 ~~i~y
Ada_,.~~. _
Date of Birth: Date of Employment: ~ -~ ~ c
Primary Beneficiary: r/hGr' y l~ Relationship: ~-~'~~ ~~ ~°
Address.. ~~~~-t ~ c,l~ gee ~~r- a %° - - -
~ uP ~ i ~,2 ~ ~r~ 3..3~y 7 ~
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.
~~
•
Signature
~.- ~1. _ 264
Dafe itnessed
Signature of
Social Security Number
fitness or Plan Official