HomeMy WebLinkAboutPension General_Documentation_Tab 10_11/28/2005•
VII.LAGE OF TEQUESTA
GENEI EMPLOYEES PENSION TRUST FUND
ENR MENT AND BENEFICIARY DESIGNATION FORM
I, ~~~~ ~~ f~~„p,,,,1-,~ , 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 employmem, I hereby designate the
following Beneficiary(ies) to receive my death benefit from the Plan:
Name of Participant: o
~I Address: 3d ~
3~1,
•
Date of Birth: 4 3 '~
~~ ~
Date of Employment: , V ~ ~ s v
Primary Beneficiary: ~ ~ Relationship: d`
Address: ~J l „~,~(' ~ /~, ~- „ S~ ~ , u
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. a
~ s ~ _~_. _. _ , .
Date Signed Signature of Participant Social Security Number
$ ~ ~ ~ as `~
• Date Witnessed Signature of Witness: Plan Official
Or Notary Public
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•
VII.LAGE OF TEQUESTA
GENERAL EMPLOYEES PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
I, ~~/'i~ ~o~ /~ 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: _ y/.5- is/• ! y~/~SS Q/~!/c
Date of Birth: ~ ~ •o~ G • ~ 3 Date of Employment: /D -/- D.S`~
Primary Beneficiary: ~Y~~~ ~~o~~~ Relationship: ~ ~e
Address: y /5~ /~/' l~i~i~-SS ~/~ ~/P
Contingent Beneficiary(ies):
Address: y,L ~ ~ G,~'/~~~°S-S .~~~P ~ ~'
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary. ~ //
~o-off ~ ~ ~ 7 ~~
Date Signed ~gnatur cipant Social Security Number
o, ~-off
• Date Witnessed Sign ture of Witness: Plan Official
Or Notary Public
Krb/word/forms/EPTFga~aalemployaeba~efidarydesigtaciao
VII.LAGE OF TEQUESTA
• GENERAL EMPLOYEES PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
•
I, ~~hl P~P'1 i~ d r I ~`~1 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: 1~(~~"h 1 ~ lL~l(71' l~
Address: ~ 4 ~ a ~~'~Sh i -'~ -~~
Date of Birth: ~ ' I 0 • 1) Date of Employment: (C7 • ~ ~ ~s
Primary Beneficiary: LTV id ~~ • WD~'1~1 Relationship:
Address: ~'~ I ~ ~.>'~~ I ~ ~~
Contingent Beneficiary(ies):
Address: ~~ ~ D3 ~ ~ P~ (n ('CSC T~ J~-
~OI~ t~rY~~ ~ ~'9 ~
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 Social Security Number
• Date Witnessed Signature of Witness: Plan Official
Or Notary Public
Krb/wad/forms/EPTFgenaalemployce(~efideryde~ig~tation
VII,LAGE OF TEQUESTA
• GENERAL EMPLOYEES PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
I, ~~QS CZ P la 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: Tr,,cc~ (h 0 ~ C..~C~S -~ ~
Address: 36 ~ Jc ~ nCCe ~ UJCtU ~f fQ C 2 -
Po~-~ S-t Luc;ie FL ?~ygg3
Date of Birth: ~ ~ ~ ~ t-} - ~ a Date of Employment: ~ ~ ~ ~ ~' ~ cJ
Primary Beneficiary: L~~ n d u ~ I~tLh2~ Relationship: m C7~'h~('
Address:
Contingent Beneficiary(ies):
Address:
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficia
0 ,
~n- - n- ~~, d !a -5
Date Signed
• fG -~I ~ -off
Date Witnessed
Signature of Partici t Social Security Number
~ ~~~~~;
Signature of Witness: Plan Official
Or Notary Public
Ktb/word/formt/EPTFgenaalatiployaebeneficiarydesigtation
VII,LAGE OF TEQUESTA
• GENERAL EMPLOYEES PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
I, ~~~ i GFl -} i >m 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:
T~ Iv i
~ rY'1
•
Date of Birth: C=' ~=~ `~~ ~ ~'r ~" Date of Employment: ~ ~% ~ ~~ ~~~~
Primary Beneficiary: {~i~~; r?-~.1') ~.--=l ~'-- - r71 Relationship: {-~ ~~`.~!-~ f~-"-'
Address: ~~ ~~~ " I
Contingent Beneficiary(ies): - ~=- ~`r 3 ~ ~ ~ r--1 ° i ~-_ `` '"~' t= ~ ~=- ~ ~ ~' `'" ~`
_~_.
., . -
-_ :r
Address: ~ r~ ~: ~~ r t~, ~~ t~ ~:~) ~." i-4--~ j ~--i 1=`i ~ ~}
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary.
Date
Signature of Participant
• Date Witnessed Signature of Witness: Plan Official
Or Notary Public
ial S
iCrb/word/formdEPTFgenaelemptoyeebenefiasrydesigpalion
VILLAGE OF TEQUESTA
• GENERAL EMPLOYEES PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
•
-~ Sri ~ .~ ~/, y do hereby request to participate in the General
Employees' Pension Trust Fun of the Village of Tequesta on the date as of which I am
eligible. to begin participation nder 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: L'A
Address: ~
Date of Birth: __~/~~ _ Date of Employment: _1 3 i oS~
Primary Beneficiary:
Address:
Relationship: ~ u s 1o a h
Contingent Beneficiary(ies): ~} ra ~o w ~To
Address: d'
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary^
Date
Signature of Participant
3~ ~vr-
• Date Witnessed Signature of Witness: Plan Official
Or Notary Public
~3
Social Security Number
Krb/wordlforms/EPTFgeneralemployaeba~eficisrydaig~-ation
VII,LAGE OF TEQUESTA
• GENERAL EMPLOYEES PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
r~
~~
I, ~ `j do hereby request to participate in the General
Employ ' P ion Trust and 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: ~ 3~~ ~~ ~r Y1~~
~~~ ~;~~; ex- ~L 33 ~ i 8
Date of Birth:~5 ~~~ Date of Employment: ((~ ~ ~ ~~
Primary Beneficiary: ~ ~. Relationship: ~rier~-
Address: ~ -S~P~.1-`~" C. ~(~ ~ r'' ,
~~~a , ~L ~~~~~
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.
1 \" t'~- d
Date Signed
of
Social Security Number
-l ~ -~ s ~_
• Date Witnessed Signature of Witness: Plan Official
Or Notary Public
Krb/word/forms/EPT'Fgettaalemployaebendcierydeaig~atian