HomeMy WebLinkAboutDocumentation_Pension Public Safety_Tab 07_02/05/2007•
VILLAGE OF TEQUESTA
PUBLIC SAFETY OFFICERS'
PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
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I, ~; ~~'- ~ ~~~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.
PLEASE CHECK WHICHEVERAPPLIES T YOU:
Police Department Employee ire Department Employee
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: ~ i - Cr- ~i'r- ~ ~ : v
Date e of Employment:
Primary Beneficiary: f~a~/~S.S.4 9 s„ ~ /~.ti Relationship: (~~'% ~-~
Address: `~'""~ ' ~'
Contingent Beneficiary(ies): =..i ~ N•~i N~ ~/~~ (sus ~
Address: `~ ~ ~ .~ S'~ .~~/%.t.A -S 7~
,P ,-~ ~= S'-r- ~ =-r ~ , ~ G ~- -~ X19 g' ~
The right is reserved to revoke this designati nand subject to due notice to the Trustee to
designate a new beneficiary.
U ~ ~ ~,
Date Signed Signature of Participant
c>`,-tip
Date Witnessed
Signature of Witness: Plan Official
Or Notary Public