HomeMy WebLinkAboutPension General_Documentation_Tab 11_08/06/2007 ~LLAGE OF TEQUESTA LUMP SUM BENEFIT PAYMENT AUTHORIZATION
~eneral Employees Pension Trust Fund(Rollover
1^ Public Safety Officers Pension Trust Fund ^ Distribution
PAYEE DATA Tag Form Address ^ (same as mailing
address)
Mail check to: ^ Pa ee Q Financial Institution/Direct De osit ^ Check if a ee is a beneficia
Payee Name (Last, First, Middle)
~ ~ v ~C.t1,1-~ l..,c~' Address
Address ~,~ /
~``L~+,? G_ 4bv' '~~ City
City ~ r~~ ~ ~ ~ Reason for separation of service:
^ Normal termination
Social Securi Number S - ~ ". -- cro - Zx a- Resigned
Partici ant Census Information ^ Normal retirement
Date of birth : Date of hire: '~ ^
^ Early retirement
Death benefit from the account of:
Date of entry: C~ _ ~~ _ 0 ~ Date of separation of service:` ~,
hj "~- ~'
Direct rollover Participant has elected a direct rollover
Information If yes, answer the following: ^ Yes ~ No ^
^
^
^ Disability retirement
Direct rollover to IRA
Direct rollover to qualified plan
Other
Amount of Rollover
Employer: Employee:
Total: AUTHORIZATION SIGNATURES:
FBO (Name of Participant) Finance Director Date
Account number: Secretary Board of Trustees Date
Address of financial institution: Board of Trustees Date
Distributio information pre~aged by:
`~ ~
raj , ~~:~~ ~C.,('';(. ~1~!
fft,;~
i _,
!~~' '' ~ ~.~~ !`.' "- ~' ,
'l
Distribution In ormation
Benefits Em to er Em to ee Total
Taxable ~-.~-..~
'~_
~' _ ;:~~~
, ~,
Non-taxable ;;--~, ~~ _~ .,, ~ , ~ ~~ J ~ ~.
Total gross P,, -, ,_~, "~
-fir-% ~ . ,-,~~
~~ ~%~"') , ~~ _~
~
<
20% mandatory ' ,
~~ ,"~' ~:~.e,
- ~~.
withholdin
Total check amount ;~ I
1_
Finance to verify bank balance amount
Employee Signature
Date