HomeMy WebLinkAboutDocumentation_Pension Public Safety_Tab 07_05/07/2007•
VIl.LAGE OF TEQUESTA
PUBLIC SAFETY OFFICERS'
PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
•
PLEASE CHECK WHICHEVER APPLIESTO YOU:
Police Department Employee ',I ~y.~ Fire De artment Em to ee
~- P P Y
I, , i • Y~'` i ~y-;~;,, , do hereby request to participate in the Public
Safety O ers'~Pension Tru~i 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: T %'
Address:
- -_ -
Date of Birth: _
Date of Employment: - ,1 ••ca.~,:~','
Primary Beneficiary~,~-t F>,a, (s.b~,,~ Relationship: S~~>~-d
Address.. ~ -
Contingent Beneficiary(ies):
Address:
The right is reseived to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary.
Signature
~~
~' ~ s r~
_ ~"
Date Witnessed Signature of Witness or Plan Official
•
VILLAGE OF TEQUESTA
PUBLIC SAFETY OFFICERS'
PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
•
PLEASE CHECK WHICHEVER APPLIES TO YOU:
Police Department Employee '' Fire Dcpariment Employee
I, ~ J~~m~= ` "~ "~~~~ , do hereby request to participate in the Public
Safety O ers'~Pension Truk 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: ~f~/??r_=.r_
Address: ~ ~ _ _ - __
Date of Birth: _ _ .
Primary Beneficiary
Address..
Date of Employment: - (~' ~ ~~ .~ T
L Relationship:
- ~
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.
ignature - - _ _ -
• Date Witnessed Signature of Witness or Plan Official