HomeMy WebLinkAboutDocumentation_Pension Public Safety_Tab 06C_02/18/2005Village of Tequesta
Employees' Pension Trust Fund
C LUMPSUM
B rte fi Payment Authorization
PAYEE DATA Tax Form Address ^ (same as mailing address)
Mail Check to: ^ Payee '~ Financial Institution/Direct Deposit ^ Check if Payee is a beneficiary
Payee Name (Last, Firs1t. Middle) Address
Q d ~, 1~G ~`~V
Address ~ -- City
City
wl ~-~. ~ L ~~ ~~
Social Securir.r *• Reason for separation of Service
~- Normal Termination
^ Resigned
^ Normal Retirement
Date of Birth Late of H\ir
~ ~
l
- ~~ ~ ^ Early Retirement
f
_ . ~
~ ^ Death Benefit Crom the Account o
:
Date o ntry Date o eparatlon o ervtce Name: Social Security:
-a~~o ~~~-~~
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:
FBO (Nam
e of Participant) Finance Director Date
(
1
.S1n- ~. br l~ LL
T~'~~ T
~ - I
Account Number Secretary Board of Trustees Date
~~ pia ~ ~
ddress of Financial Institution
~ Board oCTrustees Date
~ ~v ~ ~
ty ae rp o e
/1 / d G ~
~ ~ _ 1 ~ ~~ Distribution inform n
(Prepared BY)
Distribution Information
BENEFITS EMPLOYER EMPLOYEE TOTAL
Taxable
Non-Taxable ~7
~ /
Total Gross
20% Mandato Withholdin or elective
TOTAL CHECK AMOUNT ~ ~~ ~~ ~ -
Employee Signature
Forms Employces'Pcnsion Trust Fund
Rcs ucd:l/JUiOJ
Date Finance Department
250 Tequesta Drive, Smte 304
Tequesta, FL JJ469
Telephone: 561-575-6206
Fax: 561-575-6232
~~~
Village of Tequesta
Employees' Pension Trust Fund
L UMP SUM
Benefit Payment Authorization
PAYEE DATA Tax Form Address ^ (same as mailing address)
Mail Check to: 'Payee ^ Financial Institution/Direct Deposit ^ Check if Payee is a beneficiary
Payee Name (Last, First, Middle) Address
Address' , / ~ ..~ ~, ~ ~
`•' S t City
~ [.
City ~A~ ~/V a~~ ~ ~ ~~ ~ `~'
SocialSecur;~•" Reason for Separation of Service
^ Normal Termination
~ Resigned
^ Normal Retirement
Date of Birth Date of Hire
• ^ Early Retirement
~
~` ^ Death Benefit from the Account of
Date o ntry
Date of Separa
t
ion o Servtce Name: Social Security:
`
~q/ /~
)
V ~ 'V ~ - p! ""O~
Direct Rollover Participant has elected a Direct Rollover ^ Disability Retirement
^ Direct Rollover to IRA
Information [f yes, answer the following ^ Yes ^ No ^ Direct Rollover to Qualified Plane
^ Other:
Amount of Rollover AUTHORIZATION SIGNATURES:
Employer: Employee:
TOTAL:
FBO (Name of Participant) Finance Director Date
Account Number Secretary Board of Trustees Date
ddress of Financial Institution Board of Tmstees Date
ty ae tp o e
Distribution Information
(Prepared By) ~
u os
Distribution Information
~ ~_
BENEFITS EMPLOYER EMPLOYEE TOTAL
Taxable ~ ~ ~ ~ U~ J ~~~.
Non-Taxable - ~ `- `- d -
Total Gross J ~ S' ~ . ~ ~ ~ S
20% Mandatory Withholdin or elective ~ ~ ~ . ~~ ~ S1 . y o~
TOTAL CHECK AMOUNT J ~~ S• ~ ~ ~ ~ S _ l0
I-2~-as
Em Si ature Date
Finance Department
250 Tequesta Drive, Suite 304
Tequesta, FL 73469
Telephone: 561-575-6206