HomeMy WebLinkAboutPension General_Documentation_Tab 10_09/19/2007VILLAGE OF TEQUESTA LUMP SUM BENEFIT PAYMENT AUTHORIZATION
~1.General Employees Pension Trust Fund ^ Rollover
• ^ Public Safety Officers Pension Trust Fund ~-Distribution
PAYEE DATA Taa Form Address ^ (same as mailing
address)
Mail check to: ee ^ Financial Institution/Direct sit ^ Check if ee is a benefici
Payee Name ( ,First, Middl Address
-e
Address ~~~ ~ ~~ ~^ ~
C. a ~ ~~ ~V~~ ~,~ City
City ~ i ~V+_
~ L ~ ~~~ .~
"(V ~" Reason for separation of service:
` ^ Normal termination
Social Securi Number ~}- Resigned
Partici ant Census Information ^ Norn~al retirement
Date of birth : Date of hire: /
~ `'
~
~ ~ ~~ ^ Early retirement
'
O
! ^ Death benefit from the aceount of:
Date of entry: Date of separation of service:
Q ~ ~ ' ~-~ " O.S~
Direct rollover 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
Employer. Employee:
Total: AUTHORIZATION SIGNATURES:
O (Name of Participant) Finance Duector Date
Account number: Secretary Board of Trustees Date
Address of fmancial institution: Board of Trustees Date
Distribution information prepared by:
I
L
Distribution In ormation
Benefits Em to er Em to ee Total
Taxable
~l, oR~,~-o
~I o~~~ a-o
Non-taxable
Total gross
20% mandatory
withhol ' or elective
Total check amount
Employee Signature
Date
VILLAGE OF TEQUESTA LUMP SUM BENEFIT PAYMENT AUTHORIZATION
l~'General Employees Pension Trust Fund ^ Rollover
• 0 Public Safety Officers Pension Trust Fund ~ Distribution
PAYEE DATA Tan Form Address 0 (same as mailing
address)
Mail check to: Pa ee ^ Financial Institution/Direct sit ^ Check if ee is a benefic'
Payee Name First, Middle), Address
vv-Q- I t
Address J S ~ b S ~
~
o ~M ( ~~~c ~ City
City ~
'
c
"
~ ~
~
~ L` ~
~ Reason for separation of service:
1
l fl
+~ ~ ~ ,
~ ~ Normal termination
Social Securi Number ^ Resigned
Partici ant Census Information ^ Normal retirement
Date of birth :
3
~ ~~ ~ ~ Date of hire: ~ _ ~ ~ _ a ( ^ Early retirement
' ^ Death benefit from the account of:
Date of entry:
'-~ lb-vl Date of separation of service:
8-~ -os'
Direct rollover Participant has elected a direct rollover 0 Disability retirement
^ Direct rollover to IRA
Information ff yes, answer the following: ^ Yes ^ No p Direct rollover to qualified plan
^ Other
Amount of Rollover
Employer: Employee:
Total: AUTHORIZATION SIGNATURES:
O (Name of Participant) Finance Director Date
Account number: Secretary Board of Trustees Date
Address of financial institution: Board of Trustees Date
Distribution information prepared by:
Distribution Information
Benefits Em to er Em to ee Total
Taxable
Non-taacable
Total gross
20% mandatory
withholdin or elective
Total check amount
Employee Signature
Date