Pera Member Form History Of Rock And Roll And Popular Culture printable pdf download

Member Information Form

8324109

Colorado Public Employees’ Retirement Association

PO Box 5800, Denver, Colorado 80217-5800

303-832-9550 or 1-800-759-PERA (7372)

Fax: 303-863-3727

Read the reverse side before completing this form. Type or print in black ink, and sign below. Please do not send photocopies of this form or staple,

tape, or glue items to it. If you are a new member, give the form to your personnel office to send to PERA. If you are changing information PERA has

on file, send it to PERA and provide your employer with a copy. Changes made on this form take effect upon receipt of the completed form at PERA.

Do not complete this form if you are a PERA retiree or need to change your PERA-sponsored life insurance or 401(k) Plan beneficiary(ies), or your

PERA Defined Contribution Plan name, address, phone number, or beneficiary(ies). (See “To Members Changing Information” on reverse.)

SSN

Member Information—to be completed by you.

New Member

Changing Colorado PERA Information (Fill in name and any information you are changing and sign.)

Member __________________________________________________________________________________________________________

Last Name

First Name

Middle Name

Former Name

Male

Home

Work

(

)

(

)

Birthdate ________________

Sex:

Female

Telephone ________________________

Telephone _______________________

Month/Day/Year

Mailing Address ____________________________________________________________________________________________________

Street, Route, or Box Number, and Apt. Number

City

State

ZIP Code

Spouse ___________________________________________________________________ Spouse’s Birthdate ________________________

Last Name

First Name

Middle Name

Month/Day/Year

Named Beneficiary(ies) (Primary and Contingent) of Your PERA Account: If you die and no monthly benefits are payable, a lump-sum

payment will be made to your primary beneficiary(ies). If your primary beneficiary(ies) predeceases you, payment will be made to your contingent

beneficiary(ies). If you do not designate a named beneficiary or your named beneficiary(ies) is deceased, payment will be made to your estate. No law

shall apply to automatically revoke a spouse’s designation as a named beneficiary upon your divorce, annulment, or any dissolution or declaration

of invalidity of your marriage. Completion of this form is the only method of changing or revoking a named beneficiary designation. For additional

named beneficiaries, enclose a list of their names, relationships, Social Security numbers, birthdates, and addresses. Sign and date any list you

enclose. If you complete any beneficiary information below and submit this form to PERA, you are canceling and replacing all of your previously

named beneficiaries. If you want to continue any previous designations, you must fully name all named beneficiaries on this form or on a separate

list submitted with this form. If you have more than one year of service, state law specifies who receives monthly benefits after you die. See the

Survivor Benefits brochure.

Primary Beneficiary: If you list more than one beneficiary (attach a separate sheet with name(s) and your signature), payment will be divided

equally among them.

_________________________________________________________________________________________________________________________

Name

Relationship

SSN

Birthdate

_________________________________________________________________________________________________________________________

Street, Route, or Box Number, and Apt. Number

City

State

ZIP Code

Contingent Beneficiary (person to receive payment if your primary beneficiary(ies) is deceased): If you list more than one beneficiary (attach a

separate sheet with name(s) and your signature), payment will be divided equally among them.

_________________________________________________________________________________________________________________________

Name

Relationship

SSN

Birthdate

_________________________________________________________________________________________________________________________

Street, Route, or Box Number, and Apt. Number

City

State

ZIP Code

Member Signature_________________________________________________________

Date _________________________________

* * * * * TO BE COMPLETED BY EMPLOYER FOR NEW EMPLOYEES ONLY * * * * *

Employer No. _________ Employer Name _______________________________________________ Date __________________________

Starting Salary ________________________ Job Title ___________________________ Date Employed _____________________________

8/324-mbrinfo (REV 1-09)

Pera Member Form History Of Rock And Roll And Popular Culture

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