Beneficiary Designation Form - Calstrs Forms

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BENEFICIARY DESIGNATION FORM
q457 PLAN
q403(b) PLAN
PERSONAL INFORMATION
(please print clearly using black or blue ink)
NAME: _____________________________________________________ SOCIAL SECURITY NUMBER: _______________________________
ADDRESS: _______________________________________________________________ APT: ____________________________________
CITY: _____________________________________________________ STATE: _________ ZIP CODE: _______________________________
DAY PHONE: ________________________________________________ EVENING PHONE: ________________________________________
EMAIL: _________________________________________________________________________ DATE OF BIRTH: ______ /______ /______
MARITAL STATUS:
SCHOOL DISTRICT PLAN NUMBER: _____________________________
q
q
I am married.
I am NOT married.
If my spouse is not the sole Primary Beneficiary, my
I understand that if I become married in
spouse has signed the spousal consent. If my spouse does
the future, this form automatically ceases to apply and I
not sign such consent, I understand that any death benefits under the
should file a new beneficiary designation.
Plan will automatically be payable in full to my surviving spouse.
INSTRUCTIONS
1. You can make or change your beneficiary designations by speaking with a Customer Service Associate or go online. Please contact a Customer Service
Associate at 844-electP2 (844-353-2872) (TTY/TTD users call 800-468-5449) or go online at .
2. You may access the online tool under Personal Information to elect your beneficiary(ies).
3. If you designate a trust as a beneficiary, please include the trust name and trust date.
4. If you are married, please note that your sole Primary Beneficiary must be your spouse unless you complete Spousal Consent section of this form.
5. If you list more than one beneficiary, the total of all Primary and/or Contingent Beneficiaries must be in whole increments and equal 100%. If you
need to add additional names, please use the back of this form clearly labeling Primary or Contingent Beneficiaries.
6. If your Primary Beneficiary(ies) die(s) before you, then Plan benefits will be distributed to Contingent Beneficiary(ies).
7. If a primary beneficiary dies prior to distribution, the remaining account will be divided equally amongst the surviving primary beneficiaries.
8. Good order is receipt of the designated location of this form accurately and entirely completed, and includes all necessary signatures. If this form is not
received in good order, as we determine, it may be returned to you for correction and process upon re-submission at our designated location.
9. If you are enrolled in both the 403(b) and 457 plans and want to elect different beneficiaries for both plans, you will need to complete a separate form.
PRIMARY BENEFICIARY(IES)
Percent of Benefit*
Social Security
Relationship
Full Name and Address
Date of Birth
Number
to You
(Whole % only, must
total 100%)
_______________ ___ /___ /_____
_ _ _ .
00%
1
M M
D D
Y Y Y Y
_______________ ___ /___ /_____
__ __ .
00%
2
M M
D D
Y Y Y Y
_______________ ___ /___ /_____
__ __ .
3
00%
M M
D D
Y Y Y Y
_______________ ___ /___ /_____
__ __ .
00%
4
M M
D D
Y Y Y Y
* If you list more than one beneficiary, the total of all Primary Beneficiaries must be in whole increments and equal 100%.
100%
If your elections do not equal 100%, your form will be rejected.
CZ400CZ1BENEMAY
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