HomeMy WebLinkAboutPension General_Documentation_Tab 09_08/07/2006VILLAGE OF TEQUESTA LUMP SUM BENEFIT PAYMENT AUTHORIZATION
• ;~-Oeneral Employees Pension Trust Fund ^ Rollover ~~~~~~'~`
^ Public Safety Officers Pension Trust Fund "Distribution ~~,~~,,f"
PAYEE DATA Taz Form Address ^ (same as mailing
address)
Mail check to: Pa ee ^ Financial Institution/Direct De osit ^ Check if a ee is a benefici
Payee Name (Last, First, Middle) Address
Address City
City (, ~ L-/ ~~ t r ~
~
~ -- ~.,~
~ ' Reason for separation of service:
u-:-.~~ ~ _ _ _ (
- ^ Normal termination
Social Securit .Number _
- ~' i(` jr ~' Resigned
Partici ant Census Information
~ ~J Normal retirement
Datz of birth : Date of hire:
S~
" 3 ~ - ~
~
~
~
~~ ^ Early retirement
~
~
°, ' -
-
~ ~ Death benefit from the account of:
Date of entry:
Date of separation of service:
_
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 AUTHORIZATION SIGNATURES:
Employer: Employee:
,-
` _-
_ ,'
Total: ~ '
FBO (Name of Participant) Finance rec
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r Dat
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t
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t e
Account number: s Date
Address of financial institution: Board of Trustees Date //
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Distribution information prepared by:
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Distribution Information
Benefits Em to er Em to ee Total
Taxable
_
Non-taxable
~ ~ ~
d .-..
Total gross __ - ,- {{
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e
S tea. r= ~ r 1 i° -.~ ...- f' f
20% mandatory ,,~'~~
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withholding ,~ ~ ~ ~ ~
Total check amount -
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employee Signature Date }
.VILLAGE OF TEQUESTA LUMP SUM BENEFIT PAYMENT AUTHORIZATION
® General Employees Pension Trust Fund ^ Rlollover
^ Public Safety Officers Pension Trust Fund ®DistributionG~/~;~~~~/
.. :J
PAYEE DATA Tag Form Address ^ (same as mailing
address)
Mail check to: f~ Pa ee C Financial Institution/Direct De osit 0 Check if a ee is a benefici
Payee Name !r act Firct Mirlrilel - A.iA~o~~
n of service:
nination
cement
Went
it from the account oF.
:tirement
ver to IRA
ver to qualified plan
SiGIYATURES:
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Dat
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// Date
``
Date
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on prepared by: .
Total
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°..i,AGE OF TEQUESTA LUMP SUM BENEFIT PAYMENT AUTHORIZATION
® General Employees Pension Trust Fund ^ Rollover
^ Public Safety Officers Pension Trust Fund ~,/~~ „
~'!~(Distribution ~~~~~~/~' `„
PAYEE DATA Tax Form Address ^ (same as mailing Y
address)
,~
Mail check to: Pa ee ^ Financial Institution/Direct De osit ^ Check if a ee is a benefici
Payee Name (Last, First, MiddleZ Address
Address n I City
Clty 'r
Social Security Number
Participant Census Information
Date of b~rt Date of hire:
S 'I s ~g ~-- S"'~- ~Gs
Date of entry: Date of separation of service:
~~~~~"~ `~6~C{~
Dtrect rollover Participant has elected a direct rollover
Information If yes, answer the following: ^ Yes ^ No
Amount of Rollover
Employer: Employee:
Total:
(Name of Participant)
Account number:
Address of financial institution:
Reason for separation of service:
~- Normal termination
Resigned
^ Normal retirement
^ Early retirement
^ Death benefit from the account of:
0
^ Disability retirement
^ Direct rollover to IRA
^ Direct rollover to qualified plan
Other
AUTHORIZA ION SI AT S:
A.IA~t, . ~~ Chi ~~~,3 e~b
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/, b spy. ~~ ~ ~
~q 5 ~
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rtn =~`-~ '"
dd .,~
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(Y Date ^
'~~ ob
u ees~~,.v , A.- Date /
Board of Trustees
~--L-- ~ . J~.~~J ~ -~ Date ice,
~ ~ ~ ` C~~o•
Distribution information prepared by:
~-'~~~Q~~~C
4~~ l ~~
Distribution Infnrmatinn
Benefits Em to er Em to ee Total
Taxable -- - -
_ _
Non-taxable
`~'
Total gross ~ ~ ^ ~ ~ ~
~J '~~
20% mandatory
withholdin -
~~ /. ~.~-~
~ ~ ~-
Total check amount Q
r
Ernp oyee ignature [[[~~~~
~~~/-~~
Date
V-iLLAGE OF TEQUESTA LUMP SUM BENEFIT PAYMENT AUTHORIZATION
.General Employees Pension Trust Fund
^ Public Safety Officers Pension Trust Fund
^ Rollover
t® D' `.-^
' P~-YEE DATA ~"`
Tax Form Address ^ (same as mailing
address)
Mail check to: (~
Pa ee ^ Fi
i
.
nanc
al Institution/Direct De osit
Payee Name (Last First, Middle) ^ Check if a ee is a beneficia
Address
Address i ~ I
( City
-(u,y~
y
City
J `~ ~L ~ Reason for separation of service:
^ N
Social Securi umber ormal termination
-
Partici ant Census f nformatioo ~ Resigned
Date of birth :
Date of hire:
` ~ S ~ ~/" a ~ Normal retirement
^ Early retirement
Date of en Date of separation of service:
. ^ Death benefit from the account of:
- 6 -
~ - 0 6
Direct rollover Parti
i
h
l
e
c
pant
as e
ect
d a direct rollover ^ Disability retirement
Information If yes, answer the following: 0 Yes ^ No ^ Direct rollover to IRA
^ Direct .rollover to qualified plan
^ Other
~+muoui ui xouover
Employer: Employee: AUTHORIZATION SIGNATURES:
Total: ~
I F Name of Participant)
Finn Director ~ ,o ~6
ate
Account number: Secretary Board of Truste
~~ Date
Address of financial institution: Boa d of Trustees
Date
~/3 ~~
Distribution info t' prepared y:
.
Distributcon In ormation
Benefits Em to er
Taxable Em to ee Total
D - Z~ X70. ~
Non-taxable
Total gross
0 /o mandatory
withholding J
Total check amount
Finance to verify bank balance amount
ployee `gnature 7 O
D to