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HomeMy WebLinkAboutDocumentation_Pension Public Safety_Tab 08_11/06/2006 VII..LAGE OF TEQUESTA PUBLIC SAFETY OFFICERS' PENSION TRUST FUND ENROLLMENT AND BENEFICIARY DESIGNATION FORM • PLEASE CHECK WHICHEVER APPLIES TO YOU: r,~ Police Department Employee )Ere Department Employee V~ iW~SG ~~1~~~~' ~ ~~ I, `,1\~ f ~~1`~ , ~~~ c~~Pti~ , do hereby request to participate in the Public Safety Officers' Pension Trust Fund of the Vllage 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: ~~ ne 55A Sm o~ ~ Address: 5a1 ~o a~yerl~o~-t Q~ ' ~ ~ c ~ 9~1 Date of Birth: ~ ~~Tg~IS Date of Employment: i c~ ©1 Primary Beneficiary: Yle~~h S n-.a1e~r Relationship: 1 J~~zt~ Address: _ 5110 ~~ve~ ~~~i ~. Sk~zr~F 1=~p, 3~g41 Contingent Beneficiary(ies): 5~~ ~~~ ~~ S~SZ n ~ 1~~ Sc~a C Pz rep } ~~_ Address: '1~i'15 ~ ~' C+a~c.~ ~4 Note ~ o~ n~ 1' 1(~ ~JJ~I J7 The right is reserved to revoke this designation and subject to due notice to the Trustee to designate a new benefici~. ' n Signed Signature of Parti • Date itnessed ~gnature of Witr Or Notary Public Social Security Number KATHERINE HATOS MY COMMISSION # DD 239568 Plan BwWed Thru Notary Public Undenvrilers