HomeMy WebLinkAboutDocumentation_Pension Public Safety_Tab 08_11/05/2007•
VII-,CAGE OF TEQUESTA
PUBLIC SAFETY OFFICERS'
PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
•
•
PLEASE CHECK WHICHEVER APPLIES TO YOU:
Police Department Employee ire Department Employee ~,__„_ /`~_
I, ~ ~ S . "r ~ - . - ' ,~~_ , do hereby request to participate in the Public
Safety O ers'~Pension True 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 Partici ant:
Address:
Date of Birth: Date of Employment: - /~,~,~ }CG-~
Primary Beneficiary~~}~~Sft~Hf2 ~~%Relationship:~z~a~L-~2
Address.. _ 1L1~ % ~'~ ~l;.~i - ~~ _ _
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.
Social Security Number
-- - ~ ~ V ~ ------- -__~.,..y Y-~.~ - -
Date Witnessed Signature of Witness or Plan Official
C]
VII,LAGE OF TEQUESTA
PUBLIC SAFETY OFFICERS'
PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
•
PLEASE CHECK WHICHEVER APPLtrES TO YOU:
.~
Police Department Employee ;# ~'"~ lire Department Employee
I, ~ yt ~k~%l~ }J~~^ ._., , do hereby request to participate in the Public
Safety 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: _ ~,~''i ~' - - ~n ;~w a ~=- t-~..: _
Address:
Date of Birth:. Date of Employment: ~ - ~ /; ~,~,~_
Primary Beneficiary: ~ '~ ~ ~. Relationship: '~~~'~~;"
Address., i~-~"~/a ~,v~~l i~;~~- _ K,rrc~,~,~~,t= «.L~ L~: ~3~~~
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 ~' " Social Security Number
Date Witnessed Signature of Witness or Plan Official