HomeMy WebLinkAboutPension General_Documentation_Tab 07_11/05/2007VII.LAGE OF TEQUESTA
• GENERAL EMPLOYEES PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
•
"
I, ,..z~ ~~ ~~-do hereby request to participate in the General
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 terms and
conditions of the Plan as provided to me and agree to the terms and conditions 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: K~ n n ~-~-~ ~ n~! ~ -
Address: ~~ ~YJi'~.a~~c~:°' ,~,1. GtrC~S:+.~'
/ ~
Date of Birth: ~ ~ ~+ _~~%~~_
Date of Employment: ~~` i J.ot~ i~-
Primary Beneficiary: ~~/ e ,L'i}rr~~,~C,- Relationship: ~.. .~~
Address: '
Contingent Beneficiary(ies):
Address: j j ~ .,lr~r~ ~/ ,
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary.
q /.~ Z~
Date caned
~.
Signature of Participant
-~~
• Date Witnessed Signature of Witness: Plan Official
Or Notary Public
Social Security Number
Krb/word/fonns/EPTFgai eralemployeeb~eficiarydesignation
•
VII.LAGE OF TEQUESTA
GENERAL EMPLOYEES PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
I, t~~/~//~-~~ ~~,1~~ do hereby request to participate in the General
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 terms and
conditions of the Plan as provided to me and agree to the terms and conditions 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:
Address:
~ ~.
~~~ , ,
0
Date of Birth: r:' ~' ~ ' ~,a
"~ 7
~.:K3
Date of Employment: l~`, ` ~~'~
---
PrimaryBeneficiary: G,+l~l~ : ,`'~ ~~ Relationship: ~'~.'~,~~~
Address: ~ a ~ /~ 1 W r~'":,~-~.~,~~ ~-"~ ~ ~E....-
Contingent Beneficiary(ies): ~°>~ T/~
Address: /~-.~- ~ ~/'/~.J tt ~°~t'~~~ ~=3 3~
~~ ~~ L~
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary.
F+-•
~~
to
Signature of Partici
Social Security Number
3y~ a
• Date Witnessed Signature of Witness: Plan Official
Or Notary Public
Krb/word/forms/EPTFgen eralemployeeb~e£ciarydesignation
•
•
VII,LAGE OF TEQUESTA
GENERAL EMPLOYEES PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
1 ~ '.i" ,
Employees' Pension T st Fund of the
eligible to begin participation under th
conditions of the Plan as provided to
Plan.
do hereby request to participate in the General
Village of Tequesta on the date as of which I am
.terms of the Plan. I understand the terms and
ne and agree to the terms and condifions of the
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:
Date of Birth: ~1 ~ d~~ ~~- ~ . _ Date of Employment: ~ ~~ ~ C,i ~~ `~ .,1,d;
N
Address:
Primary Beneficiary: /~9wl~j~l~~ ~~r'Il~~lr~;/~d Relationship:
Address: ~ ,~ ;~~,/~'
-;
Contingent Beneficiary(ies):
Address:
r""~
i'
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiac~. .,,
~, t.a
Date
of Participant
• Date Witnessed Signature of Witness: Plan Official
Or Notary Public
Krb/word/forrnc/EPT'Fgaieralemployaebaieficiarydesignalion
~,A
Social Security Number
~~',