HomeMy WebLinkAboutDocumentation_Pension Public Safety_Tab 08_02/14/2006 VII..LAGE OF TEQUESTA
PUBLIC SAFETY OFFICERS'
PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
PLEASE CHECK WHICHEVER AP$~GIES TO YOU:
Police Department Employee ~// Fire Department Employee
I, /~~~ Z r'~ /I/ ~ 1 e r , do hereby request to participate in the Public
Safety Officers' 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 General
Provisions of the Plan as provided to me and agree to the Provisions 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: - ,/z 9S zr
Addre:
Date of Birth: _ l J -B 2 - 14 S7 Date of Employment: /'l -1 y - 2 vo J`
• - l
Primary Beneficiary: K ~ ~ S
Address: /Z ~ S~ c w ~
~r Relationship: SD ~
~w:~~~ ~L 3~~~d'
Contingent Beneficiary(ies): ~u~ ~ a ~. /~e ie ~ au cr sok
Address: I L p -Shat-w d~o~l, G i• /313
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary.
Date Signed
.~~`
of Participant Social Security Number
Date Witnessed Signature of Witness: Plan Official
• Or Notary Public
VILLAGE OF TEQUESTA
PUBLIC SAFETY OFFICERS'
PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
•
PLEASE CHECK WHICHEVER APPLIES TO YOU:
Police Depra~rtm~1ent Emrployee Fire Department Employee
~I, ~ CYO W`~ (JC~.~t°~ , do hereby request to participate in the Public
Safety Officers' 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 General
Provisions of the Plan as provided to me and agree to the Provisions 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: (z
x.~t°./L~l
Date of Birth: / - ,2 G - ~ ~ Date of Employment: / ~ - Z -as'
Primary Beneficiary: MP,~ti~~ ~~ C~e~'n Relationship: I~ i Fe
Address: L
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.
~.-~ v~
Date Signed
Signature of Participant Social Security Number
• Date Witnessed Signature of Witness: Plan Official
Or Notary Public
ILLAGE OF TEQUESTA
PUBLIC SAFETY OFFICERS PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
•
I, M Klx 1 M l I A y~t,_ I ~ ( l...Y~ , do hereby request to participate in the Public
Safety Officers' 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 general
provisions of the Plan as provided to me and agree to the provisions 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: __I q~~ y, ~ ~,{ p~ I k
Addt ~ - "
Hate of Birth:
Date of Employment: ~/ 1 ~ 1200 b
Primary Beneficiary: ~he~Y ~ LG((v Relationship: ~.,{p-{-I.,R~
Adores "" ' '' -
- ~ - -- --
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. ;
6
-~1-~~
Date Witnessed
Signature of Witness: Plan Official
Or Notary Public
,~ yv "il-
Social Security
•