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HomeMy WebLinkAboutDocumentation_Pension Public Safety_Tab 10_11/05/2007D%STItI~iIT3€JI+9 FC~3{P+s LUMP SU~+i -PARTIAL -SINGLE DISBI9R5E~IEEIT ~Aillage oL Tequesta - Pub16c Safeiry ®ffece~s' l~e~zseoe~ "~r<~e~Q: iF~ea~~ PLAN Pi6iME ~Al~Tac: IJrAII TO PAYEF ADDRESS: ._-~ SAME ~#~ID103784 ~C~~3CDNT NElMBER St~C3~l ~ECLlR~YY NIINCBER i+iAIL TO: GIRT!-! DATE: ~ ~ ~~'~ ~ ~ ~ TOTAL DISTRIBUTION AARTIAL DLTRIBUTION DATE OF HIRE: ~ t ~ _j ,~ V' '~ kVORMAL DLSTRIBUTION EARLY DISTRIBUTION DATE OF TERM: ' ~ ~ ~ ~ A G' ~~ DISA3ILt-fl' PAYMER~'f DEA.TN, BENEFIT DISABILITY OR DEATH DU E TO IN-LINE-OF DUTY? Y OR N TYPE OF D35TRIBUTION; Lump sum PUBLIC SAFETY OFFICERS Y OR N DROP, SHARE, MEDICAL SUPPLEMENT, 13TH C HECK, REPJNO Of CONTRIBUT10N5, iUMP SUM BE NEFIT, ETC TAX CODE: ~,. - 'I .~ TOTAL GROSS AMOUNT: ~ ..... ..-.. .- ~.~ ,..-.. ~ i~.-' ~, ,s °- ~ .~ j - :-_~~ ,.`) _:_ 1 92t7~LLOVER INFORf~IATI TOTAL TAXABLE: ~'~ IFAPPLICABLE ' "'1N-TAXABLE EEC: ~ ~.,.., . ~~ ~ ..y ' ~ ,_,,~ RAL tNITHHOLDING: ~ ~~ ~ ~ ~ ~ ~ 4~ ~ ~ p ` ~, f TAX: 1i =- r r ~''y. ~ F~j `' e `~~A( OTHER DEDUCTIONS: -r' ~-; ~~~,/ TOTAL NET CHECK: ~ ~°' ~_,.J`- ~ ~+ . ;~~. ~ I ` ~ ~_-... SHOULD PART%CIPANT'S TAX REPORTIPIG ~`I.ET99R~ lFEEF:EC'i' "T'lAXRBLC L~~tAF&' IfiE€FT` 6~H: €ERF~I6t~2" l E~ N® Si~ECY:~L flii'iT£S; vg's see` • ~._~!-_.... On File AUTHORY~NG SEGNATUR.E AE~C3 LT6I.TE SACfM TRUST COMP~~f ~ ~ ` ~ ` ~ ~ Y ~ ~~ PREPARED BY APPRO~lED BY DATE DATE ~~~s~~ ~~~~~~~ ~~ 1 ~='/~.~ C. Q'om' ` •~[ Y' RETURN BY • VILLAGE OF TEQUESTA C, Lump Sum Benefit Payment Authorization For Public Safety Officers Pension Trust Fund ~';~f~ ._ _C_~G~c' wish to apply for ollove /Distribution of my benefits from Salem Trust. Thank you. ~~ .- =~-___ Employee Signature ~ ~~~ ~~ Date • Village of Tequesta Date: 08/21 /2007 Time: 09:33:31 Retirement Code: PENSF Interest Rate: 0.0000 iployee Name Employee ID Soc Sec Number Pension Gross FYTD Pension Bal Beg of FY Interest Beg of FY Curr.Year Total Contrib. Contrib. ~SS, CHRISTOPHER 3639 $46,215.90 $7,724.07 $0.00 $2,819.16 $10,543.23 Total Employees: 1 $46,215.90 $7,724.07 $0.00 $2,819.16 $10,543.23 Total Retirement Codes: 1 $46,215.90 $7,724.07 $0.00 $2,819.16 $10,543.23 • • Page 1 I3iSTRIBi.3TIUN F03tt+i - PAR7~AL - >~~,,t, ~ ~/illage of Tequesta - Public Safety O(fecers' Pensioev Te-ust E~~ PLAN NAME ~~ a --~ ~- ~'_~~ PARTICIPANT NAME FIATL TO PAYEE ADDRESS: S©CIAL SECUR37Y NUMBER MAIL TO: BiR7}i DATE: ~` ~ ,.-~~~ , ~ ~ TOTAL DISTRIBUTION ?ARTIAL. DISTRIBUTION r~ DATE OF HIRE: ~;~ ,4 ~ ~ ~) ~i ( NORNtAL DISTRIBUTION CARLY DISTRIBUTION ^~ , DATE OF TERM: ~j ~ ~aL S ~J i~f DISABILFtY PAYMENrT DEATH BENEFIT DISA82LiTY OR DEATH DUE TO IN-LINE-OF DUTY? Y OR N TYPE OF fliSTRIBUTiON: Lump sum PUBLIC SAFETY OFFICER? Y OR N DROP, SHARE, MEDICAL SUPPLEMENT, 13ff{ CHECK, REFUND OF CONTRIBUTIONS, LUMP SU M BENEFIT, ETC TAX CODE: TOTAL GROSSAMOUNT: -~'~.,,,; C-~~--' . ~,.~ ROLLflilER INfORMATIOR9: % " ' ~ ' TOTAL FAXABLE: ~ " " - ~~ .~ " ; NON-TAXABLE EEC: ~ ERAL WITHHOLDING: '"~~~~-- it , ~~ TAX: ~~~~~ i OTHER DEDUCTIONS; ;-+:." TOTAL NET CHECK: i ~ , "i.,~~~ :~~ i (~ ~' i~ =~ / !, , . ~ , ~ SHOULD PARTICIPANT'S TAX 62PcPORTIN~ ~Lf19SlRji. REFLECT "T.4XABLE6iPIIES~1PfI NO'@' EYE'EERF~IBIEQ^ ~~ @~6® S~ECIAi NO'PES: ~ On File :` ~. „ r% .. ~s-,~,- _...__.___ . _ ~~ `; y A THORIs ING SEGNR,TEARE ,AND €EATE - f.I€F'Fp€ORTFIN~ ~g~s@NATURE ,~19~® E2ATE /~ '~ SALEM TRUST COMPANY USE PREPARED BY DATE RETURN BY APPROVED BY DAB #80103784 ACCEDUNT NUMBEit ~'~ • DISTRI$iJTIO~i FORM LUMP SUM -PARTIAL -SINGLE DISBURSEMENT Village of Tequesta - Public 5afet~r Officers' Pension Trust Fund #80103784 PLAN NAME ACCOUNT NUMBER 1~(~-~hF ( ~ ~ Gil MAYL TO DArFF ADDRESS: NAME SOCIAL SECURITY NUMBER MAIL TO: ~;. BiRT7-~ DATE: ~ , ~ ~,~J~~ TOTAL DISTRIBUTION ?ARTIAL DISTRi8UT10N -7 DATE OF HIRE: ~ ` J ~~ f ~ ? NORrIaL DLSTRIBUTION EARLY DISTRIBUTION DATE OF TERM: ~ ~ ~-~ S(J ~~ DISABILITY PAYMENT DEATH BENEFIT DISABILITY OR DEATH DUE TO IN-LINE-OF DUTY? Y OR N TYPE OF D~TRIBUTION: Lurttp aum PUBLIC SAFETY OFFICER? Y OR N DROP, SHARE, MEDICAL SUPPLEMENT, 13TH CHECK, REFUND OF CONTRIBUTIONS, LUMP SUM BENEFIT, ETC 'f,J(CODE: ~~ ~ ~~ ' TOTAL GROSS AMOUNT: ~:~ • ROLLOi1 ERINFORMATION: TOTAL TAXABLE: (~ 1FAaaucaece / ~ ~) , ({~(~, NON-TAXABLE EEC: =_RAL WITHHOLDING: ~r- ~ ,,~ S•TAX: 1 ~ X-~ OTHER DEDUCTIONS: ~G/ J ~ ~ TOTAL NET CHECK: ~ ~ , ~! ; ~~ ~, SHOULD PARTICYPANT'S TAX REPORTIP/G (1099R} PtEFLECI "'fAXABLG AMQUNT INOT DETERIyRNEO" 'iFES ~~ SPECIAL NOTfS: On File f/f/Vj r/ ~fAU~i` AUTHORIZIN SALEM TRUST COMPANY USE' PREPARED BY APPROVED BY • DATE DATE AUTk1tARIZING SIGNATURE ABA 6DATE (~ G~~I~n Trt ~ r+~s 4 r cal RETURN BY 9~ry o7 OISTRiSUTiON f1'~FiP+s Li1MP SUM -PARTIAL' SINGLE DISBURSEMENT pillage ~` Tequesta - Public Safety Officers' Pension Trust l=and #80103784 PLAN NAME ACCOUNT NUMBER _ ~~~{,~~ pus -e ~ ~ ~ti~~~~~~~~ PARTICIAANT NAME ~,~` M~.. _.......__ ADDRESS BIRTH DATE: DATE OF HIRE: S©CIAL SECURITY NUMBER MAIL TO: j `/ j L~ ~ ~~~ ~ J TOTAL DUTRiBUTION ~C ~ ~~ ~ NORMAL DISTRIBUTION ~` ( ."E ` ?ARTIAL DISTRIBUTION EARLY DLSTRIBUTION DATE OF TERM: "~ y~ I SV ~ DISABILITY PAYMER~T DEATH BENEFIT DISABILITY OR DEATH DUE TO IN-12NE-OF DUTY? Y OR N TYPE Of DISTRIBUTION: Lump sum PUBLIC SAFETY OFFICERS Y OR N DROP, SHARE, MEDICAL SUPPLEMENT, 13TH CHECK, REFUND OF CONTRIBUTIONS, LUMP SUM BENEFIT, ETC TAX CODE: C~ TOTAL GROSS AMOUNT: ~ ~ ~ ~ ~ 1 ROLLOVER INFORMATION; rFaPCUCASCE TOTAL TAXABLE: I / NON-TAXABLE EEC: _ ~ ~~ ~ ,~ ~ ~ ~ :RAL WITHHOLAING: ~~~ ~ ~ t ...~ S' ~ 5•TAX ~ ~- : N / ~~ OTHER DEDUCTIONS: ~ c~ ~ TOTAL NET CHECK: ----~- ~ ~ c~ ~ ~-- C~ ' n~ a c n SHOULD PARTICIPANT'S TAX REPORTING (i049R). REFEECT "TAXABLE AMQ~FlDFT NO'r DETERMNED° YES ~ -+ ~ D SPECIAL MOTES; »v ~ ~ ~v~ve...¢saas .7cv~v~af Vnc nct4r VAi.[ C SALEM 7HUST COMPANY USE. PREPARED BY APPROVED BY • AllTHORI~NG S',IGNATURE AND DATE RETURN BY VILLAGE OF TEQUESTA Lump Sum Benefit Payment Authorization ._...... _ For ublic Safety ~rs Pension Trust Fund I ~~~~~ _~ `~~;,,.~,(,~ (Firefighter/Police) wish to apply for a Rollover / istrib n of my benefits from the Public Safety Officers' Pension Trust Fund ' Thank you. _ Jam''%~~ ~ , ~ ~- Employee ignature • ~~ //n~ ~G° ~" Date ~~ ~ ~ (~ =~`' >~ ~ ''; ~~ ~.: ; ~_..- l-l 3 ': (~ ~«~. ~1 y I ~~ T9iSTTtISUTiOTV FORS LUMP SUM - PARTII~L -SINGLE DISBURSEP9ENT of Tequesta - Public Safety Of~eCers' Pen. ~ Trust Fune1 #801®3784 PLAN NAME i ACCOUNT NUMBER ! ~ PARTICIPANT NAME I ` SOCIAL SECURITY NUMBER ADDRESS: -b~ wvFAIL TO P ~ ~ ~ ~ ~ ~ ~ ~ ~~ MAIL TO: I ~ ~ ~ Bi12TH DATE: t ~ , TOTAL DISTRIBUTIOTV _~ ?ARTIAL DISTRIBUTION l.~ 9 ~ ~~ ~ ORINA DISTRIBITION EARLY DISTRIBUTION DATE OF HIRE: / V . N L DATE OF TERM: ~~ ~~~ S ~ ~~ DISA3ILCfY RAYMERrT DEATH BENEFIT DISABILITY OR DEATH DUE TO IN-LINE-OF DUTY? Y OR N TYPE OF DISTRIBUTION: Lump sum PUBLIC SAFET'( OFFICER? ~~,0R N DROP, SHARE, MEDICAL SUPPLEMENT, 13TH CHECK, REFUND OF CONTRIBU110N5, LUMP SUM BENEFIT, ETC TAx cooE: TOTAL GROSS AMOUNT: TOTAL TAXABLE: NnN-TAXABLE EEC: L WITHHOLDING: S TAX: OTHER DEDUCTIONS: i C''°~--~ r1 ~-I . ~i ~r~~i ~t~~ ~_~ ~: ~ ~ ,~.',m>' (.~`~~+ ' t "s' R{3iLOilfR INfORAgATiOlN; IFAPPLICABLE TOTAL NET CHECK: ~1` . ~ J~:~J ;-~ ~~~ e~^ ` .^ i ;~~: ~...._. SHOULD PARTICYPANT'S TA7t REPORTINCs (1L198Rj REFLEC6 "T'AXABLE GiMOUNr EYOY DFfCRP~INIEI3° lE~ PdO SPECIAL NO'T'ES: On File ~ ~ ~ .~~/~~~ f~~ :'.G~~ .~lf ~+/" //~L~~ ~~ . ... _ .. ~. C~~7 l~•-+c •~•~:+~ ~, ~ i h/ ..., J^ AUTHORI~%NG S%GNATURE AID FA6lTE AEs"Fk€C~R%ZINfr BIGE~TFFRE 9F~dD €9ElTE j jr% c~/~ SALEM 77ZU57 COMPANY USE' PREPARED $Y GATE 3~ETURN BY APPROVED BY DATE •