HomeMy WebLinkAboutDocumentation_Pension Public Safety_Tab 09_02/14/2006
VILLAGE OF TEQUESTA
PUBLIC SAFETY OFFICERS PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
h ~Iflm ~ S ~3 1 t'u b~' , 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: _ ;j,~n~~S l3. ~Trube
Address:
i..
Date of Birth: ~j /) y- / j y ~~ Date of Employment: 8 / ~, /I y y "3
Primary Beneficiary: '~/ cfi ; ; ~ ~ i;-~, E,~~ Relationship: U,/; f
Address: _ ~ ~ - ~ -'-
Contingent Beneficiary(ies): ~;-„~rv C., ~itu(,t:: ~,~~% /~j,;,~C~ y~~ /rt. ~~cfe.~h,;~ {f~-
Address: `2'~''S.~~ ~ i„/ !~ !~~~h:;,-,-.~ ~-~ ;r ~"
l i-3 ~~~ I `, t~. l...fc` r c IN " j`t. cl c~ ~~.
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary.
"j / ~~-~
Date Signed
.'
Date Witness
Iµ , '~]
of Participant
~- : -
Signature of Witness:
Or Notary Public
Social Security Number
~. ., ...I ; P,NU ,
~,~'' KATHERINE HATOS
?-~ - .; MY COMMISSION t DD 239568
'~ EXPIRES: August 6, 2007
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