HomeMy WebLinkAboutDocumentation_Pension Public Safety_Tab 08_05/07/2007• VILLAGE OF TEQUESTA
PUBLIC SAFETY OFFICERS'
PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
•
C,
PLEASE CHECK WHICHEVER APPLES TO YOU:
Police Department Employee ~ ~~ l+~re Department Employee
I ' ° ~ ~ ~' - ~ , 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 Participant:
Address: - -
Date of Birth: ~ _
Primary Beneficiary:
Address..
-emu _.
- -,:
F Date of Employment: -~.,~~,iZ:
-_ -_ _ _ t ~
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.
v•p--_
~-,.1 • ~ ~ .,. ~ `.,~
Date Witnessed
Signature of Witness or Plan Official