AFFIDAVIT ACKNOWLEDGING THAT NO QDROs EXIST
DISSTRIBUTING ANY PORTION OF MEMBER’S
BENEFITS DUE FROM THE FUND
STATE OF FLORIDA)
COUNTY OF
)
I, _________________________________, being duly sworn, hereby depose and state as
follows:
1. I am a member in the Deerfield Beach Police Pension Fund applying for
benefits from the fund.
2. At the time of submission of this application, there is no QDRO that exists
distributing any interest in my Deerfield Beach Police Pension Fund account
to any former spouse (s).
FURTHER AFFIANT SAYETH NAUGHT.
_____________________________
Member’s Signature
The foregoing instrument was subscribed, sworn to, and acknowledged before me this
_______th day of _____________, 200__, by ________________________________,
who is personally known _______ to me or has produced _______________________ as
identification and did/did not take an oath.
_____________________________
Notary Public
My commission expires:
__________
Date
_____________________________
Printed, typed, or stamped name