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VILLAGE OF 'I'EQ~TES'I'A
GENERAL, EMPLOYEES PENSIOl~i 'I'RLIS'I' FICTNI-
ENR®LLMEN~' AND BENEFICIARY I)ESIGNATI®N F®R1VI
I, '~~~ " i~,;, (` ~`~ ~~~ do hereby request to participate in the General
Employees' Pe sih on 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 terms and
conditions of the Plan as provided to me and agree to the terms and conditions 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:
Date of Birth: ~~~ ~-`-~" \C~~`~.- Date of Employment: ~~~ ~ ~~
r
Primary Beneficiary: ;~ ` ,~~,(~ ~ ~, Relationship: '`ja~('~~`~~'~.~ „
Address: ~`;~ ~.~~T ~,
Contingent Beneficiary(ies):
Address: \~~[.~~~ "~.,~ l~ \
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary.
Date Signed Signature ~' Partiipant
• Date it essed Signature of itn ss: Plan Official
Or Notary Public
Social Security Number
Krb/w ord/forms/EPTFger~ eralemp loyeebenefici arydesi gnation
•
~.LAGE OF 'TEQUESTA
GEr~IERAL EMPLOYEES PENSION TRUST FU1~lI-
EIVItOLLMENT AND BENEFICIARY DESIGNATION FORD
~.
I, ~ ~~~-~~ ~ ~°=~~,'~~' do hereby request to participate in the General
Employees' 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 terms and
conditions of the Plan as provided to me and agree to the terms and conditions 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:
y
~ u
Date of Birth: ~ ~ ~ t, "~ ~ Date of Employment:~ ~ ~ ~ ~'~~
Primary Beneficiary: , ~y;~-,~ ~. ~; e~_ ~.~a~E,,~. Relationship: `~~;,ti~
Address: P~'w ~ ~ s~n~ ~~ '1~`~-
t~
Contingent Beneficiary(ies): ,~yviy ~ '~•;,~y Liz...
Address: fYE:~ ~~ •~~iv+~ ~ d
The right is reserved to revoke this designation and subject to due notice to the Trustee to
designate a new beneficiary. ,,,
i Z ~~~
Si
of Participant
Date itnessed Signature of Witness: Plan Official
Or Notary Public
~~cial Security Number
Krb/word/forms/EPT'Fga~ eralemp loyeeba~efici arydesi gnation