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HomeMy WebLinkAboutPension General_Documentation_Tab 08_11/05/2007^ PubLc Safety Officers Pennon TrushFund ^ Distr ton VILLAGE OF TEQUESTA LUMP SUM BENEFIT PAYMENT AUT RI~Z,~ I General Employees Pension Trust Fund ~ollover i~yv - ,-_ AYEE DATA Tax Form Address ^ (same as mailing ~ address) Mail check to: f:' Payee fti~Financial Institution/Direct De osit Ia Check if payee is a beneficiary Payee Name ( First, iddl) Address ~ a ~ ~. ~ -~ Address City C;ty ~ ~~~ ~L 3~ y~ ~ Reason for separation of service: - ~ !J Normal termination Social Securi Number ~? Resigned Partici ant Census Information C I Normal retirement Date of bi J 1 ~ ~0 Date of hire: ~,.~ y ~ , C b ~ C I Early retirement L I Death benefit from the account of: Date of entry: .~ ,. Cb Date of separation of service: _~ Direct rollover Participant has elected a direct rollover 1-1 Disability retirement CI Direct rollover to IRA Information If yes, answer the following: I 1 Yes I ! No I_i Direct rollover to qualified plan Ll Other I Amount of Rollover ,,,..----• I ~~~~ j Employer: Employee:/)Z't~t=~~lC'~IC...lrl(%' AiJTHORIZATION SIGNATURES: (YI ~~ ~/ . ~~: ` O (Name of Participant) Finance~vect©r ... ""' ._... Da , Account number: 1 1 ~ ~ ~ 7 ~ a Secretary;' oaTd of Trus -'-~ ~ ~~~` DatdT~ -~ ~~ --~ . r_± N Address of financial institution: Board of T ees ate r~l- ; :_ r 1) r' ~ ~ ~- > ~ /~ (~ ~~Ci Y I ~ ~ ' ~ / Distribution information pr pared b : N V ---; .-9 1 C. ~ ~ + / l - G':~ / ®"- (fir' ~ Distribution Information Benefits Em to er Em to ee Total Taxable ,,r- ~'" ,-~,,: y. ,~. ,4+C"~ Non-taxable ~ °~ ., - '`~ ~ i Total gross - - -~ ~ ., ~ _ , 20% mandatory /,r~~ , ~ ;, ~~ withholding lam ,~ r Total check amount ., -" 1 ;~. • ployee Signature %~~ ~~ C Dat _`-j,