HomeMy WebLinkAboutDocumentation_Pension Public Safety_Tab 08_08/04/2008VILLAGE OF TEQUESTA
PUBLIC SAFETY OFFICERS9
PENSION TRUST FUND
ENROLLMENT AND BENEFICIARY DESIGNATION FORM
C7
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PLEASE CHECK WHICHEVER APPLIES TO YOU:
Police Department Employee FSre Department Employee
I ' -~/~ .~ ~ ~J~/JI , do hereby request to participate in the Public
Safety O ers'~Pension Truk rund 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: ~~~'s ~~~ -_ e ;/~ ~~
/'~~~ri~>,~~ ~1~'" _ ,%~~` . ~`~~ ~ ~5~.~ _ ate- ~'~~~~~?
Date of Birth: 0 ® ~ Date of Employment: - ~~ 1os ®~
i-y ry: ~!'~
Prima Beneficia
Address.. Sp'~ ®~~•-C
'~ ;;. ~~ ~ i~'6, c~~ ~~~~`Relationship: 4:.>, ~`ti-
~~ ~ ''~' '- "' ~~ Y
e~:~-- - /~/~.~,~i:° ' ~ - -
Contingent Beneficiary(ies): ,~ t`• s~% ~, a'~f r cz~~°.~e~
Address: ~,~~ / f-~'~cJft
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary.
Signature
_ `~ a~ _
Date essed
°~_
Signature of Witness or Plan Official