Return of Contributions
Application
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Separation
*
-
Month
-
Day
Year
Date
Return of Contributions amount
*
I certify that my answers are true and complete to the best of my knowledge. I agree that neither the Board of Trustees, nor the City of North Miami shall be liable for honoring any information contained in this report. Completion of this application constitutes an election regarding receipt of my pension benefits. It is a crime for a person to willfully and knowingly make or cause to be made or to assist, conspire with or urge another to make, or cause to be made any false, fraudulent or misleading oral or written statement, withhold, or conceal material information to obtain any benefit from a retirement plan. In addition to any applicable criminal penalty upon conviction, a participant or beneficiary of the plan may, at the discretion of The Board of Trustees, forfeit the right to receive any or all benefits to which the participant would otherwise be entitled.
*
Please initial
Signature
*
Continue
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Should be Empty: