HomeMy WebLinkAboutDocumentation_Pension Public Safety_Tab 09_08/06/2007~~1,AGE ®F TE,QLTEST'A LUMP SI11VI ~El®'EFIT' PAI'I~EI~T AL"~'I~®RIZA'~'Y®~
^ General Employees Pension Trust Fund
~'Pllb1iC Safety ®fficers Pension Trust Fund
^ Rollover ~
;~ 1)1Stlf'1butlol- -F "g ° °~°~.
E DATA Tax Form Address ^ (same as trailing
address)
Mail check to: ~ Pa ee C Financial Institution/Direct De osit ^ Check if a ee is a beneficia
Payee Name Gast, First, Middle)
~
~ Address
Ci ~- t L
(,~
(
Address City
Ciry Reason for separation of sen~ice:
^ Normal temvnation
Social Securi .Number r~
~ Resigned ~ - ~l `~
Partici ant Census [nformation 0 Normal retirement
.Date of birth : Date of hire: _ .~ C Early retirement
^ Death benefit from the account of:
Date of entry:. ~ Date of sep anon of service:
--~
7
~
t
,
3 - ~
~
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Direct rollover Participant has elected a direct rollover C Disability retirement
^ Direct rollover to IRA
]nformation If yes, answer the following: 0 Yes C No 0 Direct rollover to qualified plan
t u Other
Amount of Rollover AUTHORIZATI®N SIGNATURES:
Employer: Employee: , - - ;
Total: ~
..._. _
L ~ 9~
(Name of Participant) Finance `~ or" D to
Account number: Trustees - Date
- ~ r3~
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_. _
Address of financial institution: rustees Date
Distribu
+tion information pr
ep~red by:
n
~
Distribution In ormation
Benefits Em to er Em to ee Total
Taxable
Non-taxable
Total gross l_ ~~ ~ ~ ~
~ ~
~
t
~
r
:
20°io mandatory
withholding ~ ~-
~ ~ {~ ~ ~ ~ ~.
~ ~ ~7 ,
Total check amount
• Finance to verify. bank balance amount
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Employee Signature Date °