Beneficiary Designation Form - Calstrs Forms Page 2
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3BENEFICIARY DESIGNATION FORM
SPOUSAL CONSENT
(If spouse is not the sole Primary Beneficiary)
Your spouse must consent and acknowledge by signing below if he/she is not the sole Primary Beneficiary.
(1)
I hereby consent to the foregoing election by my spouse, to have his/her benefits paid to a person other than me. I understand
that the effect of such
designation is to cause my spouse’s death benefit to be paid to a beneficiary other than me;
(2)
that each beneficiary designated is not valid unless I
consent to it; and (3) that my consent is irrevocable unless my spouse revokes the beneficiary designation.
I hereby acknowledge that I have had the opportunity to consult with an attorney or other professional concerning this waiver, if I had so desired.
Executed this _____________ day of ____________________________ 20 _____
Spouse’s Signature
Print Name
:
WITNESSED BY
(only ONE required )
Plan Representative Signature
Print Name
Notary Signature
Print Name
CONTINGENT BENEFICIARY(IES)
Percent of Benefit*
Social Security
Relationship
Full Name and Address
Date of Birth
Number
to You
(Whole % only, must
total 100%)
_______________ ___ /___ /_____
_ _ _ .
1
00%
M M
D D
Y Y Y Y
_______________ ___ /___ /_____
__ __ .
00%
2
M M
D D
Y Y Y Y
_______________ ___ /___ /_____
__ __ .
00%
3
M M
D D
Y Y Y Y
_______________ ___ /___ /_____
__ __ .
00%
4
M M
D D
Y Y Y Y
100%
*If you list more than one beneficiary, the total of all Contingent Beneficiaries must be in whole increments and equal 100%.
If your elections do not equal 100%, your form will be rejected.
BENEFICIARY DESIGNATION FORM / PAGE 2 of 3
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