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HomeMy WebLinkAboutDocumentation_Pension Public Safety_Tab 06_05/10/2005~ c~-~ 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 l do hereby request to participate in the Public Safety Offic '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: ~ ~ ~~ /~ i~atn ~c~. ~n ~ Address: ~ ~ - ~---- ~ -- - . Date of B~h -~ / ~ ~ - C`, Date of Employment: p ~-1 - ©Ll - c~~~ Primary Beneficiary: 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. r}~i- ~~ Date Signed of Participant Social Security Number Date Witnessed Signature of Witness: Plan Official Or Notary Public QC (a) VII.LAGE OF TEQUESTA PUBLIC SAFETY OFFICERS' PENSION TRUST FUND ENROLLMENT AND BENEFICIARY DESIGNATION FORM PLEASE CHECK WffiCHEVER APPLIES TO YOU: * f Police Department Employee Dire Department Employee i7~ 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: ~~~..;,~ F~~ae_e,~' _ Addre~~~ '_ _ _ Date of Birth: iI/~ 3/7ct Date of Employment: 15 0 Primary Beneficiary: ~~ -bIG- 1-~ we ~ ~ Relationship: ~ ~ 1. ~~" Address: IR~~1~' G~,1-CS-icru,~.. ps - - T,~L~:~~ F"1 3 346 ~' -- 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. Social Security Number -~,,as Date Witnessed Signature of Witness: Plan Official Or Notary Public