HomeMy WebLinkAboutDocumentation_Pension Public Safety_Tab 08_02/05/ 007VILLAGE OF TEQUESTA LUMP SUM BENEFIT PAYMENT AUTHORIZATION
^ General Employees Pension Trust Fund ^ Rollover _
I~.Public Safety Officers Pension Trust Fund f,~~istribution '~; d° ~~~,-~,-~~~.,
• °'
PAYEE DATA Tax Form Address ^ (same as mailing
address)
Mail check to: Pa ee ^ Financial Institution/Direct De osit ^ Check if a ee is a beneficia
Payee Name (Last, First, Middle , Address
Address City
Ciry
~~'~~ "`` ~1~ ~ "~ (..~``+~ ~'~'*~l ~ ~ J ~ ~~<~ Reasoq for separation of service:
^ Normal termination
Social Securit Nurr~ ,y~, Resigned
Partici ant Census Information ~ Normal retirement
Date of birth : I' ~ ~ ,7 Date of hire: i I ~ ~ _~ S- ^ Early retirement
^ .Death benefit from the account of:
Date of entry: Date of separation of service:
~1~~~.GS~ 1/~ 3-c6 ~
Direct rollover Participant has elected a direct rollover ^ Disability retirement
^ Direct rollover to IRA
Information If yes, answer the following: ^ Yes ^ No ^ Direct rollover to qualified plan
^ Other
Amount of Rollover AUTHORIZATION SIGNATURES:
Employer: Employee:
Total , ~ -.._.....w._ ~,.-. ~. .~r, ....
,.
_.a~
~
~
O (Name of Participant) w
Finance ~ irector Date
' Account number: oard ust to / ~
Address of financial institution: B d of T tee / ~~
~~~. Date /
""yy G~.
istr' n
inf rmation prepared by:
,
~, / , Q~ , 7~~~~0(~
Distribution Information
Benefits Em to er Em to ee Total
Taxable l /
Non-taxable
Total gross ~O _ ~~ ~o~~ •
20% mandatory
withholdin , /O ~ ~
~f - ~ ~~
Total check amount // Q~
l~ ~ l . ~~
• Finance to verify bank balance arrlount
ploy e Signature Date
~.~
1LLAGE OF TEQUESTA LUMP SUM BENEFIT PAYMENT AUTHORIZATI
^ General Employees Pension Trust Fund ^ Rollover ~ ~- .
~'ublic Safety Officers Pension Trust Fund ~ Distributi~~~ C
• ~ - - ~-
PAYEE DATA Tax Form Address ^ (same as mailing
address)
Mail check to: a ee ^ Financial Institution/Direct De osit ^ Check if a ee is a beneficia
Payee Name (Last, First, Middle) Address
~ tL~~
Address ~ ~ City
City 7 ~ ('
~~
'~
~ ~
~~ ~ Reason for separation of service:
yjL'~
_
-~ ~_ ^ Normal termination
Social Securit .Number ~
~ ~ .~( Resigned
Partici ant Census Information ~ Normal retirement
Date of birth : Date of hire: ~
~' ~ 0 -5 3 ~ ~~ ~~~ ^ Early retirement
^ Death benefit from the account of:
Date of entry: , , Date of separation of service:
a-7 .,~ ~
Direct rollover Participant has elected a direct rollover ^ Disability retirement
^ Direct rollover to IRA
Information If yes, answer the following: ^ Yes ~ No ^ Direct rollover to qualified plan
^ Other
Amount of Rollover AUTHORIZATION SIGNATURES:
Employer: Employee:
Total: ~'
.....
f !_ ''" <_
(Name of Participant) Financ ~ r ..-~= `"~ `" Date
-~= ~ ~ ~ziz; r~ ~
Account number: Board of Trustees Date
~. ,
/`
Address of financial institution: Board ofTrustees Date
Distribution inform tion prepared by: / / /~
~`-I" v
Distribution Information
Benefits Em to er Em to ee Total
Taxable
~~~ ~. ~.~
~a~ ~. ~3
Non-taxable
Total gross ~~ ~ ~ ~ ~ ~/
20% mandatory
withholding
-
D l//--~~L/// /
/ v'T ~ . C~D
Total check amount
~ ~ Finance to verify bank bala e mo t
l~ = ~ 1 ~ ~ ~''~-~
Employee Signature Date