Designation Of Beneficiary For Community Property - Lacers
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DESIGNATION OF BENEFICIARY FOR COMMUNITY PROPERTY
(FOR NON-MEMBER OR FORMER/SEPARATED SPOUSE) - ALL MEMBERS
NOTE: Any benefit overpayment that LACERS cannot collect will be deducted from benefits
payable to your beneficiary(ies).
I, ________________________________________, Social Security Number __________________,
(Print your name)
am receiving, or entitled to receive, my community property share of the retirement allowance,
contributions of _____________________________, Social Security Number __________________
(Your Ex-Spouse’s Name)
and/or the retirement allowance of his/her survivor, if applicable.
I hereby designate the following primary beneficiary(ies) to receive my community property share in
the event of my death including any accrued allowance:
________________________________________________ _______________________________
Name
Date of Birth
___________________________ _________________________________ __________________
Relationship
Social Security Number (Optional)
Telephone Number
___________________________ ________________________ ________ _________________
Street Address (No P.O. Boxes)
City
State
Zip Code
________________________________________________ _______________________________
Name
Date of Birth
___________________________ _________________________________ __________________
Relationship
Social Security Number (Optional)
Telephone Number
___________________________ ________________________ ________ _________________
Street Address (No P.O. Boxes)
City
State
Zip Code
(Unless you indicate otherwise when you designate your primary beneficiary(ies), your community
property share will be paid in equal shares to any primary beneficiaries who survive you.)
To name additional primary or secondary beneficiaries, initial here _____ are fill out the back of this
form.
If the primary beneficiary(ies) named above are deceased, I then designate the following
secondary beneficiary(ies):
________________________________________________ _______________________________
Name
Date of Birth
___________________________ _________________________________ __________________
Relationship
Social Security Number (Optional)
Telephone Number
___________________________ ________________________ ________ _________________
Street Address (No P.O. Boxes)
City
State
Zip Code
_____________________________________________ __________________________________
Applicant’s Signature
Date
1 of 2
12/05/2014
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