HomeMy WebLinkAboutPension General_Documentation_Tab 10_11/06/2006VILLAGE OF TEQUESTA
.GENERAL EMPLOYEES PENSION TRUST FUND.
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
I,~ Y~~~~~~~~~ ~ ~!/j('~~ do hereby request to participate in the General
Employees' 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 terms and
conditions of the Plan as provided to me and agree to the terms and conditions 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: ~'j i~l~i `~ tl'/~= ~~ /~~;1 ~'~1 ~~.~~~
Address: f ~% ~ ~ ~ti dl ~ ~i/UI ~2~(/S ~ I~ „2
_ t
Date of Birth: ~ ~..5 `? ~ Date of Employment: ~ 7 ~` ~
Primary Beneficiary:
Address: ` C~ ~~ C22'~~"J f ~e~Zd~>~~ ~
_,
~~
Contingent Beneficiary(ies):
Address:
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary.
..
of Participant Social Security Number
Date Witnessed Signature of Witness: Plan Official
Or Notary Public
Krb/word/forms/EP1'Fgaieralemployeeba-eficiarydesi8natian
VILLAGE OF TEQUESTA
GENERAL EMPLOYEES PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
I, ~ a u~; ~I S c L ~ ~~ do hereby request to participate in the General
Employees' 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 terms and
conditions of the Plan as provided to me and agree to the terms and conditions 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:
Address: 31rN~ ~ ~ ~ ,Q t / ~
~~~ ~ ~~« ~ ~ ~t ~-d~~1 ~ ;
Date of Birth: o `~ i l ~ ~ Date of Employment: ~Z ' d G_~
Primary Beneficiary:;~'~~~Z(~ • ~c r- ~_ Relationship: ~~~r~F,~
Address: 3 (~ ~f `1 ~- L - ~ ~--~ ~
~~~ v~ u ~ ~ ~' ~ ~ l,. C r~r~ ~-~~
Contingent Beneficiary(ies):
Address:
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary.
U~l,~s~l~`t:~
Signature of Particip
Social Security Number
.., ~,
Date Witnessed Signature of Witness: Plan Official
Or Notary Public
Krb/word/forms/EPTFga~eralemployueba~eficiarydesignation
VILLAGE OF TEQUESTA
GENERAL EMPLOYEES PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
I, ~ ,~ ,) ~~ r- ~ ~ ~ ~ ~- ~~~ ~~c~' p.;~~ do hereby request to participate in the General
Employees' 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 terms and
conditions of the Plan as provided to me and agree to the teens and conditions 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:
~~ .
!! :,~ ~%~
Address: l..E (~ 1 ~ i ~/' ~;%'~:~ i t;(~U
Date of Birth: ! ^~"~~ a~ '-'"-^•" `°' Date of Employment: i ~,~ . ~ `- l.~'~~
Primary Beneficiary .. ~ ~'~ r~ ~ ~ ~z k~~ ~~,-, Relationship: t~~~ ~ ~ ":~f} -~~ C
Address: ~ ~' ~~ ~ ~~ ~ ~'~ +C: ~~ : j ~ ~, ~ .~J Y;
Contingent Beneficiary(ies): ~ '~ - ~ ~~' ~~ = .~ ~y~~t ~ ~'~~ -~--'
Address:
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary. /
b... --
Date Signed Signature of Participant Social Security Number
Date Witnessed Signature of Witness: Plan Official
Or Notary Public
Krb/word/fortnslEPTFgeneralemployeeba~e~ciarydesignation
VII,LAGE OF TEQUESTA
GENERAL EMPLOYEES PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
I, ~ ~,r ~~ ~~`l i'~'S do hereby request to participate in the General
Employees' 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 terms and
conditions of the Plan as provided to me and agree to the terms and conditions 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: (~ ~~ r- ~ \-~ ~.~ s-'`-~
~--
Address: ~ 5 ~ ~ S ~ ~- ~~`'~- S ~
Date of Birth: l ~ ~- ~ ` - ~ ~ Date of Employment: ) U - ~ ~ -' ~ ~
Primary Beneficiary: R ~, C_ I~ , ~ N ~~ ~.~.Relationship: i ~; v c ~i
Address: ~ ~ i ~, ~ 'vs ~~`:,0~ ~ y`~ t^ I"~V~
Contingent Beneficiary(ies):
Address:
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary.~/~
1~-I~-ut~, ~'/~LC~ ~~
Date Signed Signature of Participant Social Security Number
/~
Date Witnessed Signature of fitness: Plan Official
Or Notary Public
Krb/word/farms/EPTFga-eralemploye~eficiarydesi~ation
VII.,LAGE OF TEQUESTA
GENERAL EMPLOYEES PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
I, ~,,~yPr Pmt" ~ S do hereby request to participate in tf~e General
Employees' 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 terms and
conditions of the Plan as provided to me and agree to the terms and conditions 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: ~e/~, ~ #~~' PG. t' p ~
Address: I l 1~ ~ ~1 Q ~.~G•w
Date of Birth: j~ - j Q - 6 ~ Date of Employment: a ~~ )'~ ^ Q,6
Primary Beneficiary j jJe ~N,'s Relationship:
Address: ,S'4- e~. b Si D tit ~'# ~'uD~'~t t` ~~ ~ ~1~. Jam'
Contingent Beneficiary(ies):
Address:
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary.
~ dh i 7 ~ o~ c,~a~~pr~rl,,.o
Date Signed Signature of Participant Social Security Number
'~~ ,.. ~ -~; ~; ~`~, " Lek-Zt•t~,,
Date Witnessed Signa re of Witness: Plan Official
Or Notary Public
Krb/word/forms/EPTFgeneralurq~loyeebet-eficiarydesigrtation