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VII.,LAGE OF TEQUESTA
PUBLIC SAFETY OFFICERS'
PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
PLEASE CHECK WHICHEVER APPLIES TO YOU:
Police Department Employee
)ire Department Employee
h 4~~ ~.,~ ~ }~, ~, ~0 ~ ~ ~ ~ , 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:
Date of Birth:
Primary Beneficiary:
Address: Zd'
T~~ ~~ 3tia~
Contingent Beneficiary(ies): /l1r ~ G ~ ~ ~ ~'
Address: ZU ~ ~ A s c.u~( ~
_~ ~ ~,.. FL ~ yob
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary. ~ ~,
~t`~/L'~Id~
Date Signed
Date of Employment: O L~O 7~
~ . (, ~ 1~1.~ Relationship: Ly ~ -
ature of Participant Social Security Number
Date Witnessed i Signature of Witness: Plan Official
' Or Notary Public
C6~
VILLAGE OF TEQUESTA
PUBLIC SAFETY OFFICERS'
PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
PLEASE CHECK WHICHEVER APPLIES TO YOU:
Police Department Employee ~ F5re Department Employee
I ""-' •.~ ~ ~(_~;`,~ , 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: e ~ -, . ~ v ''n ~~ ~ ~
Address: -
Date of Birth: ~ ~ Zr Date of Employment: ~ z i ~' GQ
Primary Beneficiary: ~ .~,~, ~ e /)') ~L.~ '~, Relationship: _~;°S ~:
Address: 5 ! ` ~ ~ ~ ~ ~
Contingent Beneficiary(ies): '~ti'" r~- i ~ - _
Address: ~ / ~ t~~ y ~-
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary.
Date Signed S' nat of Participant Social Security Number
~~~'
Date Witnessed ; Sign 3 ure of Witness: Plan Official
Or Notary Public