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VII.,LAGE OF TEQUESTA
PUBLIC SAFETY OFFICERS'
PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
•
PLEASE CHECK WHICHEVER APPLIES TO YOU:
Police Department Employee
Ftire Department Employee
I, q ~ ~ ~ ~i/-0.~ , do hereby request to participate in the Public
Safety Officers' 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 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: A ~, ~,~ T 1',~~,~I ~ _
Adc
Da;
ite of Employment: ;~~ ~ ~' :~ F:r
Primary Beneficiary: ~~'-l~ E v';°~i~-'`~ Relationship: ~~...a•t'~.~-
Address: / 7'°P'~{ 5 ~ ~~ L.°>>/~ ~.Jt~~
Contingent Beneficiary(ies): ~'~ i~~~f=i5~ i? ~ ~-~1~~~ ~+1,n~~..+'S ~t"'~c~~-~'~>
Address: J ~ r.,.~. .! ;= i ~ r_ti:e..J~ ~,..~;.~.~--t
'' , ,
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary.
,.
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:a
D to Si ed Signature o~Participant
~, ~ ~~.
,~~' ,~,~_~ .,,t~,
• Date Witnessed Signature of Witness: Plan Official
Or Notary Public
•
YII-,CAGE OF TEQUESTA
PUBLIC SAFETY OFFICERS'
PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
•
Police Department Employee
PLEASE CHECK WHICHEVER APPLIES TO YOU:
~.~
la`ire Department Employee -
,~ _ _
I, Jf~~~s !~ - ll-z.. l`~„ ~- , do hereby request to participate in the Public
Safety Officers' 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 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: ~op~.( /~ . ~~~~si`/c:.~ ~-Y~-
- - - -~ - -
Address:
Date of Birt Date of Employment: j ~ .~ ~ ~}.~
i ~
Primary Beneficiary:
Address: I `'1.1 `~ <<
Relationship: ~1~TJ~~--
Contingent Beneficiary(ies): _j ~~ ~t~~~.l ~/~ I Lt;~T'/<:~ .5~'- (''_ , ~ r~r,
Address: 1`1,~ `"r ~ ~C~.l iw~ i~ ~~ ~
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary~~
-~ c v
Si ned i na ure of
~~
• Date Witnessed
t'~._..-cam;-; /,~; . ~•;~.,z-,
Signatu e of Witness: Plan Official
Or Notary Public
•
VILLAGE OF TEQUESTA
PUBLIC SAFETY OFFICERS'
PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
PLEASE CHECK WHICHEVER AP -LIES TO YOU:
Police Depart~nt Employee ire Department Employee
is
I, "~~ ~ / ~ • ~ °'~ ~ ~ , do hereby request to participate in the Public
Safety Officers' 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 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 Pa**~cioant:
Address:
i Date of Birth:
Primary Beneficia
Address: / S ~~
Date of Employment: ~ ~ /~ /o
v ~f3 ~'
Contingent Beneficiary(ies):
Address:
The right is reserved to revoke this designation and subject o due notice to the Trustee to
designate a new beneficiary.
b ~i2~~..
Date Signed
• Date Witnessed
Signature of Participant
Signature of Witness
Or Notary Public
an Official
Social Security Number