HomeMy WebLinkAboutDocumentation_Pension Public Safety_Tab 06C_05/11/2004L~ ~~
Village of Tequesta
Employees' Pension Trust Fund
LUMP SUM
Benefit Payment Authorization
PAYEE DATA Tax Form AddreSS ^ (same as mailing address)
Mail Check to: I~ Payee ^ Financial Institution/Direct Deposit ^ Check if Payee is a beneficiary
Payee Name (Last, First, Middle) Address
~tL1i. ~~ ~~h k~
Address ~ ~ ~J ~ ~ ~/1 City
City State Zip Code
Social Security Number, ~
- ~ - ~~ J Reason jor Separation of Service
O Normal Termination
~ Resigned
^ Normal Retirement
Date of Birth p
• ~ (~ ' ~ 1 Date of Hire
- I ( •- ~, ~ ^ Early Retirement
O Death Benefit from the Account oF.
ate o Entry Date o eparat3on o ervtce Name: ~ Social Security:
~~I`~-o~ -3-~~-by
Direct Rollover Participant has elected a Direct Rollover ^ Disability Retirement
Information
If yes, answer the following ^ Yes ~ No ^ Direct Rollover to IRA
^ Direct Rollover to Qualified Plan
^ Other:
Amount of Rollover AUTHORIZATION SIGNATURES:
Employer: Employee:
TOTAL:
FBO (Name of Participant) Finance Director Date
Account Number S cr t Bo of tees
r ~ Date
~/
~
..
~ ~ 1
~
ddress of Financial Institution B r ste Date
y
z ~~
w
ity State Zip Code Di bution Informati n ~y~
re ared B ~ -
Distribution Information
BENEFITS EMPLOYER EMPLOYEE TOTAL
Taxable 5918. ~~ S9i ~• 5~
Non-Taxable
Total Gross ~ % ~ 0 ~~ ~~1 J ~~
0% andato Withholdin or elective ~,Z't.. p4 ~/,~ ! ~ _ ~ / I I g3 . ~ l
TOTAL CHECK AMOUNT ~•1L14 ~/~ /Q;; / ~~ . U J ~ / ~ ! ~ U ~`
d~ r
~ Employee Signature •
Fnrtns:Empbyces'Pension Trust Fund
~-/~'~~~
Date
Finance Department
250 Tequesta Drive, Suite 304
Tequesu, FL 33469
n _ - Telephone; 561575-6206
r
VILLAGE OF TEQUESTA
PUBLIC SAFETY
PO BOX 3273
TEQUESTA, FL 33469
PAY TO
Air'
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Prudential ~ Financial t z s 4 s e~ e s o
PAYABLE THROUGH BANK ONE.COLUMBUS. NA CHEGK'ONE ~/l ~ 1
COLUMBUS OHIO <]3l+
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~:044000804~: 4 34000 7 6 5 20811'0 L8 3 •
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VILLAGE OF TEQUESTA
PUBLIC SAFETY
PO BOX 3273
TEQUESTA, FL 33469
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L~LLL' `' a
Par To
THE ORDE ( /,I r i
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Prudential Securities COMMANDS'" Account
183
25-80/410
Z. Z r1r1~
DATE
M
Prudential Securities COMMANDS"" Account
184
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DATE
I$11~~3~
`~ ~ I\'~,~ '`LEAKS J;J w.. w•,~.
i 11 ~~
Prudenttal ~ Ftnanctal C C ' '
PAYABLE 1HH000H BARK ONE. COLUMBUS. HA 1 2 ~ ~ `~ 6 7 B 9 O ~ A
co~uMBUS.o«w~~n, CHECK j ~ '~ ~~
~ . _ ' ~ ~,,
FoR ~ 7 ~ ~ r ~ L.~. ~!C L J
x:0440008 4~: ~, 34000? Z 5 20811'0 L84 '
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Village of Tequesta
Employees' Pension Trust Fund
LUMP SUM
Benefit Payment Authorization
PAYEE DATA Tax Form Address ^ (same as mailing address)
Mail Check to:~ P ayee ^ Financial Institution/Direct Deposit ^ Check if Payee is a beneficiary
Payee Name (Last, First, Middle) Address
~ C1~~-s~
Address O ~~ ~ _ J f j o ~'~ l O
/~
v( City
City State
Zip Code
L~I~ ~ ~ L 33 x/03
Social Se~ ty~N~ ber ~ ~ _ O ~ ~ ~ Reason jor Separation of Service
N
!
i
^
orma
Term
nation
Resigned
^ Normal Retirement
Date of Birth Date of Hire ^ Early Retirement
_ a, ~ -'fib ^ Dcath Benefit from the Account of:
ate o ntry e o eparahon o rntce Name: Social Security:
-a`I-~~ -s"-o~i
Direct Rollover Participant has elected a Direct Rollover ^ Disabiliry Retirement
^ Direct Rollover to IRA
Information If ycs, answer the following ^ Yes ^ No ^ Direct Rollover to Qualified Plan
O 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
Q
ity State Zip Code Distribution Informatioh .! ~
ared B
Distribution Information
BENEFITS EMPLOYER EMPLOYEE TOTAL
Taxable 0 ~~ ~ 5. ~ 3 (~ 5 7 S
Non-Taxable
Total Gross 0 ~ / S ~ ~ $~ ~~
20% Mandato Withholdin or elective ~ / f J - / 5 1 ~~ S ,
t
S
TOTAL CHECK AMOUNT jJjg J~ C
..
~P g~ ~ • J
E oyee Signa -
c _gd~ ~ _
Date ~!'~Q
Finance Department
250 Tequesta Drive, Suite 304
Tequesta. FL 33469
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