HomeMy WebLinkAboutDocumentation_Pension Public Safety_Tab 10_08/07/2006VII..LAGE OF TEQUESTA
PUBLIC SAFETY OFFICERS'
PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY bESIGNATION FORM
PLEASE CHECK WHICHEVER APPLIES TO YOU:
Police Department Employee ~~ lH~re Department Employee
I~ ~/ L~%~~ ~ ~ e ~ c.~.bxn , do hereby request to 'participate in the Pu61ic
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: _
Date of Birth:
Primary Beneficiary: Sq~„t,,;G C~+tr~~.
Address:
Date of Employment:., 7- /v- o~
Relationship: _ ~j~aks~c
,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.
Signature of Participant
_~-~,o~
Date Witnessed Signature of Witness:
Or Notary Public
Social Security Number
Plan Official