HomeMy WebLinkAboutDocumentation_Pension General_Tab 13_05/05/2008 OF TEQUESTA LUMP SUM BENEFIT PAYMENT AUTHORIZATION
~~neral Employees Pension Trust Fund
^ Public Safety Officers Pension Trust Fund
YEE DATA Tax Form Addr
address)
Mail check to: a ee Financial Institution/Direct De osit Check if a ee is a beneficia
Pa a Na (Last,. F' st, M'ddle) Address
Addres - ~~ 1 t 1 ,1,,~
l YY~ City
City
~~ c ~j. ~
T ~ ~~ `~~ Reason for separation of service:
Normal termination
Social Securi Number '~ Resigned
Partici ant Census Information , . Normal retirement
Date of birt~ Date of hire: ~ ~ ~, p~
~-' ; ; Early retirement
! ' Death benefit from the account of:
D~t entry ~ Date of separation of servi e:
Dire rollov r
Information Participant has elected dire rollover
If yes, answer the following: I ~ Yes i ! No ~ ! Disability retirement
I a Direct rollover to IRA
; ] Direct rollover to qualified plan
t ! Other
Amount of Rollover AUTHORIZATION SIGNATURES:
Employer: Employee:
'^ ;
~~
Total: ' ,~ y
~.
O (Name of Participant) ~ tna a hector Date
Account number: Secretary Board of Trustees Date
Address of financial institution: Board of Trustees Date
6></ /D p ~
Distribution inform ion p pared by:
u cx- ,~ ~ ~ _ ``.
Distribution In ormation
Benefits Em to er Em to ee Total
Taxable ~ ~ ~ ~ ~
IC~~,~ i O~ J ~ •
Non-taxable
Total gross
IO~~.~.q~
I0~`~.~. ~~_
20% mandatory
withholdin
~ U ~ ~, ~
~~ ~7~
Total check amount
J
Employee Signature
Date
^ Rollover p
Distribution ~ q-}~~~ ~-YY~c.~-1
om ~-1. f~eid
ess ^ (same as mailing 311 b' ~U,