HomeMy WebLinkAboutPension General_Documentation_Tab 11_11/06/2006VII,LAGE OF TEQUESTA
GENERAL EMPLOYEES PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
I, `'r}'i,~ ~.~ ~~) ~ ;~ ; ~ do hereby request to participate in the General
Employees' Pe io T 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: .+~ ° ~.
lr , -~ :~ e L'~ aZ~
Date of Birth: f ~ - !.,,~ - J ~,~ Date of Employment: (~ - f c~ _ ..~~~:? ~~
Primary Beneficiary:
Address:
Relationship:
,.,~~ ,I` ~' ~,• ~ ~ ~ fie.,: ~` .', ~ t..:.~
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.
~~ _ ~~~
~~ ~ .~7
ite Signed Signature
Social Security Number
L3 °_"``~ ;~;~;~'ry,~, KATHERINEHATOS
Date Witnessed S g ature of Witness: an Official ?.; .- MY COMMISSI09 # DD 239568
fir.: € EXPIRES: Au ust 6, 2007
Or Notary Public 7~~,r~ 9ondedThruNotaryPubl~cUndenvrXers
Krb/word/fo~mc/EPTFgeneralemployeebeneficiarydesignation