HomeMy WebLinkAboutDocumentation_Pension General_Tab 12_08/04/2008 LLAGE OF TEQUESTA LUMP SUM BENEFIT PAYMENT AUTHORIZATION
eneral Employees Pension Trust Fund ^ Rollover
;, Public Safety Officers Pension Trust FundDistribution
;,
AYEE DATA
Tax Form Address ^ (same as mailing address)
Mail check to: a ee Financial Institution/Direct De osit
Pa Name L t, First, Mid le) Check if a ee is a beneficiar
Address
Ad e s ~ n ~
~ City
City ~ ~
~ Reason for separation of service/termination from plan:
Social Sec it Number .
r Normal termination
Partici ant Census Infor mation - Resigned
Date of birt
ate of hire: Normal retirement
E
l
~
b ar
y retirement
~
Date of entr :
Y
ate f s oration of s ice: Full-time to Part-Time status ~ .~
O ~~ ~ ~ eath benefit from the account of:
Direct rollover
Information: Parti ipan has elected a direct r ver
^ tsability retirement
Yes ~No a Direct rollover to IRA
If yes, select from the following: Direct rollover to qualified plan
C Other
Amount of Rollover
Employer:
FBO (Name of Participant)
number:
Address of financial institution:
Distribution In
Employee:
Total:
r` ~
ormation
Benefits Em to er Em to ee
Taxable Total
Non-taxable
Total gross -~~'
~ ~<~~~
20% mandatory withholding ~~ ~".~ ~~
Total check amount `3~-i
r-
If you do NOT wish to have a rollover or contribution distribution, please select one of the following options:
^ I do not wish to receive a refund of my contributions as I have completed six (6) years service and would like to receive a
future, vested, accrued benefit, the details of which will be communicated to me in writing.
^ I have less than six (6) years service and understand that I do not qualify for a deferred pension, but would like to leave my
ontributions in the fund for ftve (5) years, pending the possibility of being rehired in a full-time position.
~(~~ ~ / (1
mployee Signature Da
( -=~
Fin n 'rZctor
o
Secretary Board c
~~~
Board of Trustees
SIGNATURES:
~ ~ L ~~
:-~'~ ,
Date '
`r_,~c~ /_ ~~~
,,~~.~-; , Date
Date
Distribution information prepared by:
( ~
,~~,-~~•
~<<-'L
Form updated: 5/9/08
/ M~IV
AGF~ O1+' 7'EQtIESTA LUMP Sl?M ~~NEk'I.T 1'A~~~F1RolIoAU7"F10RtZATICIN
,~ lLL _ i
~Gencral F.mployces penwion Trust Fund ,'; j~_~. ~ _ - ~. ~) ~~"~1)istribudun
i ~ Public Safety Officers Pension Trust fund _ _-_.-.---1-~~dress}
PAYEE UA'rA
Mail ehcck to Pu cc i Financial ]nsutution/Direct >7c~~
~Nar ~~LH~us tddlc ---- ^--
Addres. -rj(~" ~~.~
S~~ ~~_ lace--_--
Social yccuri~Number
.. ~......e..t f nn~~is ln1
L)tde of birl.h . 1~
Date orcnuy:
Direct rollover
Infurmalir~n
~'-' 7'~,~!Forti~ Ae~d[L~S t l (same AS mui rn~
t ,) Check if p?;vee is s~ 1>encfi~iar~ - _- -.-----
Address --- --_ ___--
f.~ r ~~'----
Dn _
T~aIC of birc.OC ~~ -
1)atc of sepataticui of s tvice~ --
•- lent has elc4~ 'led u due~~i~o"
Paitiitl
Yc5 ~Na
if yes. selcal from the foir lu ~inb:
~- oat o~ullovrr Einplvycc
Employer.
tgO (Name of Particip:uit)
Ac.Gnun4 numhcr
Address i~f financial institution J
Distribution In o>~mation _
~ Benefits ~_,En'~
Ta.Yablc _ __
Non-taxsblc _
Total gross
2U°./n mandatory withholding
mount i
'1'~ts~l check a
~~~%
-~'-
~-1~~_
r
~'~~
~~~~
u
r~
~I
~e~tae~ t oard of True
THORIZ Tt STGNATURFS: --,-
e
c h'Cttl(lr
and of Trustrtl~ --~
strirution inforiruition rc tired y. ~~' i 1
p P a ~ i;~ c.:., ,;i ~
]~isubilit.)• retirement
Pirccl. rohiwnr to h12J1
virect ro{iuvcr r.o qualified plan
Otbe~ ~ ---- -----
~~`~ ~~ ~' ~~
Litre
~~ `r'~ 1~0y -
a5 . ~
- llate
~,t3•~
_
"'
1)atc
_-_- To_tall~ ~ _-
-~ -1-
3(~~-7. -
If }'uu du NQT wild to have a rolTuvcr or contribution distribution, please select. +urc oT the fullowirrg nptions:
1 do nut wish to receive a rcl'und of my ooutributions as T have cumple•ted six i6j years service aria would like to receive a
futtue, vested, accrued bcne~c, the dctAils of which will be communicated to mr. iu vvritin6.
0 1 have less than six (6) years service anal understand that I do not qualify for a deferred pension, but would liicc to leave my
coriU'ibutious in the fund I'ur five (5) years, pc:ndiu6 the possibility of being rehired in a full-tithe position.
,`. _ ~ ~ ~ ~ 6 ~ .moo ~
. Employee Signature 17ate
torn, npdatcd 5/!!SUB
City __
Re9so for separation of serviceltcrminatinn Tram plan.
Norma! lerrninatirui
lJ Resigned
L1 Nnrmal rrt.ircnicnt
p E;,rly retlLCtttCnt
Full-time ti. Part-Time stan~s
U Deatb benefit from the account itif.
AU
Fin
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