HomeMy WebLinkAboutDocumentation_Pension Public Safety_Tab 05A_02/10/2004•
VILLAGE OF TEQUESTA
PUBLIC SAFETY OFFICERS'
PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
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PLEASE CHECK WHICHEVER APPLIES TO YOU:
Police Department Employee I'}re Department Employee
I, ~ f-~,~ , ,~~ TV ; ~;-~ ~ ~ ~: ~? ~ ~ , 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: >>j~ ~ ; ~ r°~I,, ~ ~ ' -,~, ; - --
Address:
Date of Birth: ~ ~ ; '~ : ~ ~' ~ Date of Employment: / ~ D~ ~ 3
Primary Beneficiary:
Address: ;~.~.~, -~
Relationship:
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.
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Date Witne
Signature of Participant
Social Security Numner
Signature o£ `JVitness: lan Official
Or Notary Public