HomeMy WebLinkAboutPension General_Documentation_Tab 08_02/04/2008VILLAGE OF TEQL'ESTA LUMP SUM BENEFIT PAYMENT AUTHORIZATION
f4~~General Employees Pension Trust Fund ^ Rollover
• ^ Public Safety Officers Pension Trust Fund ;~ distribution
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PAYEE DATA Tax Form Address ^ (same as mailing
address)
Mail check to: ~ a ee Financial Institution/Direct De osit Check if ayee is a beneficia
Payee Name (Last, First, Middle) ) Address
YV'` ~ CI
Address
~~ /+
`t' ~nY,~, ~•~ City
City Reason for separation of service:
<c ~~,,` IE`~C ~~ ~G ~ ~~1 ~'~ `~ Normal termination
Social Securi Number Resigned
Partici ant Census Information Normal retirement
Date of birt
' Date of hire: ~ /(~, OS Early retirement
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(
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Death benefit from the account o
Date of ent q
'~~-1805 Date of separation of service:
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Direct rollover Participant has elected a direct rollover Disability retirement
Direct rollover to IRA
Information If yes, answer-the following: I ! Yes No Direct rollover to qualified plan
Other
Amount of Rollover AUTHORIZATION SIGNATURES:
Employer: Employee: .__ _ __, _, A
Total:
,y
,-, ! '~ ~'
O (Name of Participant) Fina / re jo ate
Account number: Saeailm'y oard of Truste D to
Address of financial institution: Board of Trustees D e
Distribution information prepared by: ,; j ')
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1)icfrihufin» T»fnrmafin7l
L rJII iV -y irV/r a
Benefits
Em to er
Em to ee
Total
Taxable ~~\) '~~~9~ff r~ fj/` ? f ~ 1/'/p'~ ;
Non-taxable
Total gross ~-:>''` ~- ~ ~"~} '% ~ -}~ "~.~ ~ ~' ~~ ~, ~
_
20% mandatory
withholdin ~1~~.~ ~..~-~t_.~ v ~ ~ (~'Y'--°,~
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Total check amount f~ ~s
,, ~ ~ %~
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Employee Signature r~ Date ~ ,
PILLAGE OF TEQUESTA I--,UIVIP SUl®~I BE1®1EFIT PAYIVIEI~iT AUTI-I®I~IZ~.T1®I~1
C~General Employees Pension Trust Fund ^ Rollover
,~
^ Public Safety ®fficers Pension Trust Fund ~Distribution --~°°~'~;~~,: ~",~„,;:=~,,n'.~11~=~~
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AYEE DATA
Tax Form Address
address)
I '~ Check if payee is a benefici
Address
^ (same as mailing
Mail check to: ;:~i-Payee .:, Financial Institution/Direct Dew
> y
I a ee N e Last, First, Ms,
~ dle
f~ 9 _
~
~ `mod .~~ Y7 3 ~ Olen-~ ~'TG~ .
Address ;j ~~
Cit dd
y l~(,~i ~ ~~ ~ cl ~ S t `
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Social Security Number
Participant Census information
Date of bir~tyh 'y~ Dare m nnc.
Date of entry: Date of separation of service:
Direct rollover Participant has elected a direct rollover
Information If yes, answer the following: I:I Yes i ' No
City
Reason for separation of service:
1 I Normal termination
Resigned
I ! Normal retirement
I: i Early retirement
Death benefit from the account of:
Il Disability retirement
I ' Direct rollover to IRA
I_i Direct rollover to qualified plan
Other
Amount of Rollover AUTHORIZATION SIGNATURES:
Employer: Employee:
t
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l ~
:
o
a . Y-' ~
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~BO (Name of Participant) Finan ~,~ r ' Date
Account number: Bard of Trustees Date'
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Address of financial institution: Board of Trustees ~ / Date
Drstnbution yQfornaUon prepared by: t
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Distribution In ormation
Benefits Em to er Em to ee Total
Taxable ~ ~f ~t ~ ? C ~ - -;, rr-~ `~ ~ ~ , --,
1
Non-taxable ~° -,~~ ~-, ,
Total gross ~ r- ~ ~ ~ ----~
<:
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~ ~
20% mandatory ~ _
~ ~ .. ~ + „ -' '"
withholding .~ ~,.
Total check amount =' ~
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Employee Signature Date