HomeMy WebLinkAboutDocumentation_Pension General_Tab 05_04/24/2006VII,LAGE OF TEQUESTA
• GENERAL EMPLOYEES PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
I, ~„~ I~~~:?-tch 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: ~S o E ~~~~2 c c r~ -
Address: 3 ~ ~ •Z c~,,~ ~ ~~ ~, z ~- cd ~ ~;t,
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Date of Birth: (~ (, - (1- 71 Date of Employment: n3 -Z~- d ~
Primary Beneficiary:~,nY ~ci nc crc Relationship: ,. , : ~=r-=
Address: ~~~~oz ~ c~-~„ ~ ~ -
Contingent Beneficiary(ies): ~..c~~_~'~
Address:
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary.
Date Signed ature
of Participant
t 5 ~ •- 6 ~ - ~41~°ji
Social Security Number
• Date Witnessed Signature of Witness: Plan Official
Or Notary Public
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