HomeMy WebLinkAboutDocumentation_Pension Public Safety Tab 15_11/08/2005
VII..LAGE OF TEQUESTA
PUBLIC SAFETY OFFICERS'
PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
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Signature
~~
• Date Witnessed
PLEASE CHECK WffiCHEVER APPLIE O YOU:
Police Department Employee ire Department Employee
~I, ~- kr ~,kd„, Af/e~ f~,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: C.4~v,~~aph~ ~9b~~
Address:
Date of Birth: p~~g~ Date of Employment: d•S
Primary Beneficiary: ~rra,nt '737ve.~lc,il Relationship:µr~-i-~-r
Address: r/,~G, ~w,v ~~,~~- i7Q- /~p~ .~ ~1
Contingent Beneficiary(ies):
Address:
The right is reserved to revoke this
designate a new beneficiary ,
Signature of Witness: Plan Official
Or Notary Public
,, ~;
to due notice to the Trustee to
Social Security Number
• VILLAGE OF TEQUESTA
PUBLIC SAFETY OFFICERS'
PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
PLEASE CHECK WffiCHEVER APPLIES TO YOU:
Police Department Employee ~/ re Department Employee
~I, ~' ~ ~~- / ~• /"lb~~~ ~ , do hereb r uest to artici ate in the Public
Y ~1 P P
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 Particip~t: /~~ ~ ~- ~--~~ / C . ~/~lo+¢ ~.
Address: i ~ _ . _ _ _ _
• Date of Birth: _ Date of Employment:
Primary Beneficiary• ~ ioJ~ship: a
Address: 3 ~ ~ T
!L. a2oc~ ~ o~S:S a
Contingent Beneficiary(ies):
Address:
The right is reserved to revoke this designation and sub'ect to due notice to the Trustee to
designs e a w beneficiary.
ate Signed Signature of Participant Social Security Number
Q--~'~ off" ~~'-~ ~
• 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 Department Employee
Fire Department Employee (/
•I, ~~~ ,1-~~L.-v i...~ti \h~~~ , 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 Par+;cinant: ~-; ~~ ~nQ 1,-E~ ~L' ~ 1\ti. ~ l~ti•~ -
Address:
Date of Birth: ~ a. - ~ r'7 ~ Date of Employment: ~ r I~-- c= ~
Primary Beneficiary: ~~~A~, ~,~ ~~ F~ ~~~~ 1t.~-I ti•~-,Relationship:
Address:
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.
N-' ~-ter
Date Signed
j -Q
Date Witnessed
,,Y
ign t of Participant Social Security Number
Signature of Witness: Plan Official
Or Notary Public