ࡱ> '` bjbj{P{P 4D:: @@@zD&1&1&18^1$1:2:2:2:2:23338:::::::J:X&`X&4$ihъX@h433h4h4X:2:2m@6@6@6h4.8:2@:28:@6h48:@6@6(@@6:2.2 @-n&14"@660@6e4fe@6e@@6t30I3"@6k33333XX6"333h4h4h4h4  Thv  POMPANO BEACH POLICE & FIREFIGHTERS RETIREMENT SYSTEM DESIGNATION OF BENEFICIARY FORM (Active Members Only) 2335 East Atlantic Boulevard Pompano Beach, FL 33062 Name of Member:Soc. Sec. No.: Pursuant to applicable provisions of the Retirement System, I hereby make the following Beneficiary Designation for benefits in the event of my death: Name of BeneficiaryRelationshipBirth DatePRINCIPAL:CONTINGENT: If any designated Beneficiary shall predecease me, the rights and interests of such Beneficiary shall thereupon automatically terminate; in such event, any interest held by or through me by said deceased beneficiary by reason of my death and participation herein, shall cease and terminate completely. I reserve the right to change the designated Beneficiaries at any time upon filing a new written request with the Board and which request, when received by the Board, shall revoke any prior selection or designation of Beneficiary. The consent of a Beneficiary shall not be required to effectuate any change.  (Signature of Member)(Date) STATE OF _________ ____________ COUNTY OF ______________________ The foregoing instrument was acknowledged before me this ______ day of _____________________, ______ by ________________________________ (name of person acknowledging), who is personally known to me or who has produced _____________________ (type of identification) as identification and who did (did not) take an oath. __________________________________________ (Signature of Notary) F-benchg-A __________________________________________ rev.3.2005 (Name of Notary: Print, Type or Stamp)     XYnoc e f z { ˾ˤ}qmm}mq]Qh9CJOJQJ^Jh`cWh95CJOJQJ^Jh9h9CJOJQJ^Jh95CJOJQJ^JhICJOJQJ\^Jh9CJOJQJ\^Jh9CJOJQJ\^Jh Y/CJOJQJ\^JhN4'CJOJQJ\^Jh7"CJOJQJ\^Jh`5CJOJQJ^Jh Y/5CJOJQJ^Jh95CJOJQJ^J8Yo$If $dha$gd Y/$a$gd Y/$a$ c d e f z { fd___VPJ$If$If $$Ifa$$a$kd$$Ifl\<&(p064 la{ 4kd1$$Iflֈ&fy064 la $$Ifa$$If :kd"$$Iflֈ&fy064 la $$Ifa$ $$Ifa$gd $$Ifa$ / c t x 㪞u㪞hdhWhy5CJOJQJ^Jh9h95CJOJQJ^Jh9CJOJQJ^Jh95CJOJQJ^JhhI>*CJOJQJ^JhICJOJQJ^JhI5CJOJQJ^Jhyh9CJOJQJ^Jh9CJOJQJ\^Jhh9>*CJOJQJ^Jh9CJOJQJ^Jh`cWh9>*CJOJQJ^J C::::: $$Ifa$kd=$$Iflֈ&fy064 la <kdX$$Iflֈ&fy064 la $$Ifa$ <kd$$Iflֈ&fy064 la $$Ifa$ <kd$$Iflֈ&fy064 la $$Ifa$ $$Ifa$ $$Ifa$gd E<<<<< $$Ifa$kd$$Iflֈ&fy064 la <kd2 $$Iflֈ&fy064 la $$Ifa$ <kds $$Iflֈ&fy064 la $$Ifa$ <kd $$Iflֈ&fy064 la $$Ifa$ <kd $$Iflֈ&fy064 la $$Ifa$ <kd6$$Iflֈ&fy064 la $$Ifa$ $$Ifa$ . / c d E@@@@>@$a$kdw$$Iflֈ&fy064 lad e f g h $dh$Ifa$ dh$IfZkd$$IflF&Z,6    4 la $dh$Ifa$x H K ˿ueYIhyh9>*CJOJQJ^JheCJOJQJ^JhX+hy5CJOJQJ^JhX+h5CJOJQJ^JhX+h95CJOJQJ^JhX+hCJOJQJ^JhX+h9CJOJQJ^Jh9CJOJQJ^Jh9CJOJQJ^Jh95CJOJQJ^Jh9CJOJQJ\^Jh95CJOJQJ^Jh95CJOJQJ^J $%P{r{b$^`a$gdIpdh]p$a$ $dha$gdy$dha$$dh&d P a$\kdv$$IflF&Z,6    4 la #Pfpvɸ՜tg_[_[_[_[W[Sgh9hahjhUh95CJOJQJ^JhICJOJQJ^Jhv=CJOJQJ^JaJh{CJOJQJ^JaJh`CJOJQJ^JaJhICJOJQJ^JaJ hyhICJOJQJ^JaJh9CJOJQJ^Jh95CJOJQJ^Jh9CJOJQJ^J"h h95CJOJQJ\^JPf$ ^` a$gdI$a$$dh^`a$gdI2&P:p Y// =!"#$% /$$If!vh5(555p#v(#v#v#vp:V l065(555p/ / / / / / /  / 4$$If!vh5f555y55#vf#v#v#vy#v#v:V l065f555y554$$If!vh5f555y55#vf#v#v#vy#v#v:V l065f555y55/ / / 4$$If!vh5f555y55#vf#v#v#vy#v#v:V l065f555y55/ / / 4?$$If!vh5f555y55#vf#v#v#vy#v#v:V l065f555y55/ / / / / / 4$$If!vh5f555y55#vf#v#v#vy#v#v:V l065f555y55/ / / 4?$$If!vh5f555y55#vf#v#v#vy#v#v:V l065f555y55/ / / / / / 4?$$If!vh5f555y55#vf#v#v#vy#v#v:V l065f555y55/ / / / / / 4?$$If!vh5f555y55#vf#v#v#vy#v#v:V l065f555y55/ / / / / / 4?$$If!vh5f555y55#vf#v#v#vy#v#v:V l065f555y55/ / / / / / 4?$$If!vh5f555y55#vf#v#v#vy#v#v:V l065f555y55/ / / / / / 4?$$If!vh5f555y55#vf#v#v#vy#v#v:V l065f555y55/ / / / / / 4?$$If!vh5f555y55#vf#v#v#vy#v#v:V l065f555y55/ / / / / / 4i$$If!vh5f555y55#vf#v#v#vy#v#v:V l065f555y55/ / / / / / / / / 4$$If!vh5Z55,#vZ#v#v,:V l65Z55,/ / 4$$If!vh5Z55,#vZ#v#v,:V l65Z55,/ / 4<@< NormalCJ_HmH sH tH P@P Heading 1$$@&a$5>*CJOJQJ^JN@N Heading 2$$@&a$5CJOJQJ^JN@N Heading 3$$@&a$5CJOJQJ^JDA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k(No List `$@` Envelope Address!@ &+D/^@ CJ4@4 Header  !4 @4 Footer  !HB@"H Body Text$a$CJOJQJ\^JFV@1F  Y/FollowedHyperlink >*B* phD z8Yocdefz{./cdefgh$%Pf&\M&\M&\M&w&&&wPwwwww&w&w&؎&؎wG\M.\M\M.؎:\M؎wGw.ww.w:ww\MG5.ww.w:wwwGw.ww.w:wwwGw.ww.w:ww\MGw.ww.w:ww\MGw.ww.w:ww\MGw.ww.w:ww\MGw.ww.w:ww\MGw.ww.w:ww\MGw.ww.w:ww\MGw.ww.w:wwwGw.ww.w:ww&؎&w&w&w&w&؎DDTDDwDT#D&4&&w&LS&5& &\M&\M&&\M&8Yocdefz{./cdefgh$%Pf00000000 0 0 0 0 00000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000 0 0 0 0 0 0 0 00000000000h00h00h00h00h00h00h00h00h00h008Yocdefz{./cdefgh$%Pf00000000 0 0 0 0 00000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000 0 0 0 0 0 0 0 0000000000  x  { d P ! 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