HomeMy WebLinkAboutDocumentation_Pension Public Safety_Tab 05C_02/10/2004i~illage of Tequesta
Employees' Pension Trust Fund
LUMP SUM
Benefit Payment Authorization~I ~~
PAYEE DATA Tax Form Address ^ (same as mailing address)
Mail Check to: Payee ^ Financial Institution/Direct Deposit ^ Check if Payee is a beneficiary
Payee Name (Last, First, Middle) Address
~^
~rNt~ l~l SAM >C~~71' ~
Address ~ - Ciry
City Zio Code
Social Security Numb^ Reason jor Separation of Service
J4 Normal Termination
^ Resigned
^ Normal Retirement
Date of Birth /
y t7 ~ Date of Hire
3 - r) ~ ^ Early Retirement
^ Death Benefit from the Account of:
ate o ntry ate o eparatron o ervtce Name: Social Security:
~'If-a~~
Direct Rollover Participant has elected a Direct Rollover ^ Disability Retirement
^ Direct Rollover to IRA
Information If yes, answer the following ^ Yes ^ No ^ Direct Rollover to Qualified Plan
^ Other:
Amount of Rollover AUTHORIZATION SIGNATURES:
Employer: Employee:
TOTAL:
FBO (Name of Participant) Finance Director Date
Account Number Secretary Board of Trustees Date
ddress of Financial institution Board of Trustees Date
ity State Zip Code Distribution Information
Pre ared B
Distribution Information
BENEFITS EMPLOYER EMPLOYEE TOTAL
Taxable
Non-Taxable
Total Gross
20°/n Mandato Withholdin or elective
TOTAL CHECK AMOUNT
Employee Signature
Forms:Employees'Pension Trust Fund
Rcviscd:I/70/03
~-,
Date
Finance Department
250 Tequesta Drrve, Suite J04
Tequesta, FL J7469
Tclephone: 561.575-6206
Faa: 561-575-6232
Rc ~-
Village of Tequesta LUMP SUM
Employees' Pension Trust Fund Benefit Payment Authorization
PAYEE DATA Tax Form Address ^ (same as mailing address)
Mail Check to: ,l~'[?ayee ^ Financial Institutiort/Direct Deposit ^ Check if Payee is a beneficiary
Payee Name (Last, Firsst, Middle) Address
Address City
~~
.. .. - _
City State Zip Code
,~
• _e....~.... _.,_._.....____
J
Social Security Numh _ l Reason jor Separation of :Servi.-Y
^ lotmal Termination
^ Resigned
^ Nonnal Retirement
Date of Birth l/ ~ - n Date of Hire .~ ^ Early Retirement
Uirect Rollover
Information
4mount oC Rollover
Employer:
FBO (NameoCParticipant)
Account lumber
lddress of Financial Institution
ea ene t rom e . ,~ c nuns -
Date o eparatton o etvtce Name: jo~.ial S~~cunty
7
.. ~~.
Participant has elected a Direct Rollover ^ Disability Retirement
^ Direct Rollover to IRA
[f yes, answer the Collowing ^ Yes ^ No ^ Direct Rollover to Qualiti~d t`la;~
O Other:
AUTHORIZATION SIGMA"fURE'+
Employee:
TOTAL:
State Zip Code
Distribution Information
Finance IYrector
Secretary Board of Tnistee
Date
s Uate
Dai.. i
j ; j~ ,
BENEFITS EMPLOYER EMPLOYEE
Taxable ~ j ~ ~-~ , j ~ j
Non-Taxable --'"
Total Gross j ~ ' ~ '
Mandato ~Vithholdin or elective ~ (• `i
- _.
TOTAL CHECK AMOUNT --- - --- -_~~-~_ __
r ;; (:
f J~ ~ r-~r
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Employee' Signature Date ~ Lt~
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