HomeMy WebLinkAboutPension General_Documentation_Tab 06_02/05/2007
VILLAGE OF TEQUESTA
GENERAL EMPLOYEES PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
I, ~~ ~~c~, ~ , ~~~`~h ~ do hereby request to participate in the General
Employees Pension Trust Fund 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 terms and.
conditions of the Plan as provided to me and agree to the terms and conditions 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: ~ ~ "~ ~ ~ -- ~~ ~~
,Date of Employment: ~ ~ ~ ~~-!'~ ~a
Primary Beneficiary: ~~y „~ ~,~ ~',,~;~~~~ ~,~ Relationship:
Address: ~~~ ~- ~~ ~~~= .(1 w^l~ a S `=~ ~~
;,
Contingent Beneficiary(ies):
Address:
;~~ : ~~c~ ,~~ 1 Tt~s~l ~ w~ ~~ :~ ~ ~-~ ~~
T~"'7~-
ff
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficialy.
Date Signed Signature of Participant Social Security Number
"~"1 .-~
~ a_.-
• Date Witnessed Signature of Witness: Plan Official
Or Notary Public
Krb/word/fortns/EPTFgaieralemployeebeneF ciarydesignation
~
• VII.,LA,GE OF TEQUESTA
_ GENERAL EIV~PLOYEES PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
~ ~~
1 /' '~° ~_ ;~`, do hereby request to participate in the General
Emp oyees' Pension Trust Fund 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 terms and
conditions of the Plan as provided to me and agree to the terms and conditions 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: ~~ ~ ~ u ~ ~~ Q %~ ~ f
Address: ~ 5 i'~ ~ ~ .S ~ ~b ~` Gi ~ ~~ ~
~' -'~ ,~ Date of Employment: ~' - ~ ~ ~~ ~
Date of Birth: ~ - ,
• primary Beneficiary: ~ ~ Relationship: S ?r
~2~'~ ~.~ bey r..~~l/
Address: ~ ~ ~ ~
Contingent Beneficiary(ies): ~~' ~ ~ ~~ ~~
CCir lUS ~~ I~ ~ Y~ S
Address:
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary. •
Date Signed
Signature of Participant
• Date Witnessed Signature of Witness: Plan Official
Or Notary Public
~ M~ ~ ~
Social Security Number
Krb/word/forms/EPTFgeneratemployeebeneficiarydesig~ation
•
VILLAGE OF TEQUESTA
GENERAL EMPLOYEES PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
I, ~ Nt,L, ~ - ~-, do hereby request to participate in the General
Employees' Pension Trust Fund 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 terms and
conditions of the Plan as provided to me and agree to the terms and conditions 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 ~c ',~y~-~ ~ ~ j J~~ 1"
Address: ~' J ~
Date of Birth:. ~ZO ~ ~~ Date of Employment: J~,e,~ ~ ~ ~~Co
Primary Beneficiary: ~ ~' a ~~lk Relationship: j;'{ ~. ~
Address: ~ I h °! 1 V`' ~'~t L:, l/Ll- -' ~,r ~ :-
'~- ;~ ~-, ~ L ,3 ~~i ~
Contingent Beneficiary(ies): L i' ~ ~~, ~ r ~ c~- i ~ M C ~~ ~~
Address: j ~ ~~' ~ l ~~ -f-~-r rc.~-~e 6LL~
The right is reserved to revoke this esignation and subject to due notice to the Trustee to
designate a new beneficiary.
Date Signed Signature of Participant Social Security Number
Date Witnessed Signature of Witness: Plan Official
• Or Notary Public
Krb/word/formc/EPTFga~eralemployeebaief ciarydesigpation
T{' :; ,
,•
•
VILLAGE OF TEQUESTA
GENERAL EMPLOYES PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
1, ~~' ~l ~L~,a ~~ l l ~ ~~i~ do hereby request to participate in the General
Employees' Pension Trust Fund 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 terms and
conditions of the Plan as provided to me and agree to the terms and conditions 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: 1 ti ~ ' ~^~j
Date of Employment: ~ ~
Primary Beneficiary: ~ rC ~ ~ ~ ~ ~ Relationship:
Address: ~ ~~,~j~.,~ ~ S ~ d~z
Contingent Beneficiary(ies): ~,'~ ~",~ r~1L~ j 'l~id_~.t:~~ Ali
Address: S[„~,,~1~,,;,
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary.
Da a Signed Signature of Participant Social Security Number
;~~
• Date Witnessed Signature of Witness: Plan Official
Or Notary Public
Krb/wordlforms/EPTFgaieralemp loy~eficierydesignation