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VILLAGE OF TEQUESTA LUMP SUM BENEFIT PAYMENT AUTHORIZAT
^ General Employees Pension Trust Fund Rollover
~jPublic Safety Officers Pension Trust Fund ^ Distribution ` '~
AYEE DATA Tag Form Address ^ (same as;mailing
address)
Mail check to: ^ Pa ee J~ Financial Institution/Direct De sit ^ Check if a ee is a benefici
Payee Nang (Last, First, Middle) ~
~ Address
~~
7 0v~. atr+~-
Address
s 3
sw C Ce City
City Reason for separation of service:
,S'~ Q~+~ ~ (_ 3 t{ q' ~' ~ ^ Normal tertnination
Social Securi Number !J Resigned
Particl ant Census Information ^ Notmal retirement
Date of birth : Date of hire: ^ Early retirement
-o ~ ^ Death benefit from the account of:
Date of entry: Date of separation of service:
-o a ~ - a-- -o~
Direct ro lover 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: `/
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O (Name of Participant) Financ Di r ~
.~- -- ~ ate
3/i~ a~
Account number: Board o Trustees Date
a63`i9 gos~~ '
Address of financial institution: oard of Trustees to
D ~ v~o~ L `~ ~QG~C ~ / ~/ (
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LL Distribution in/formation prepnarend by:
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UIJlPLt7l[i[UII In urniui
Benefits evii
Em to er
Em to ee
Total
Taxable
Non-taxable } , ~~ ~ Ll Q+ 11 ~~(~ .1 1
Total gross I (~ ~~1 ` ( ~ (~ ~' ~ ~ ,
20% mandatory
withholdin
Total check amount ~-
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Emplo ee Ignature Date
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VILLAGE OF TEQUESTA LUMP SUM BENEFIT PAYMENT AUTHORIZATION
^ General Employees Pension Trust Fund ^ Rollover
®Public Safety Officers Pension Trust Fund ®Distribution
~~ro.~hEe,>/
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 benefici
Payee Name (ast First, Middle) ~. Address
A h.l~ l~{.
Address
a ~ s .w~
~i~ss,~ c~. City
City ~
C~
~" ~ /~ D
~~ ~ 'T ~ ~ Reason for separation of service:
^" ^ Normal ternunation
Social Securi Number 1b S~ ~ `~~ ' 3 ~ '$ ^ Resigned
Partici ant Census Information ^ Normal retirement
Date of bi _ y ~ Date of hire: D ,~,~ ~ ^ Early retirement
Q ^ Death benefit from the account of:
Date of en Date of separation of service:
Direct rollover . Participant has elected a direct rollover ^ Disability retirement
Information If yes, an
swer the following: ^ Yes ~ No ^ Direct rollover to IRA
^ Direct rollover to qualified plan
^ Other
Amount of Rollover AUTHORIZATION SIGNATURES:
Employer: Employee:
Total:
a6
BO (Name of Participant) Finance or Date
3 3 od
Account number: S ary Board of Trustees Date
32 0
Address of financial institution: Board of Trustees Da
Distribution in
fo
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ep
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red
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y
mation~
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Distribution In ormation
Benefits Em to er Em to ee Total
Taxable ~ r~~ ~1 ~`i f ~
_ + /J ! ~~f' I k I
i `i U
Iv'on-taxable
Total gross
_._ _ _
~ r ~~~ ~~ ~ I ~~
I ~C~~ I
20% mandatory
withholding
,/~
~ ~ ~~ . C.~~ ,~
J~~~~
Total check amount -~'
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Employee Signature Date