Rs 5127 - Designation Of Beneficiary With Contingent Beneficiaries
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2___________________________________________________________________________________ _
For Office Use Only
Receipt Date
Designation of Beneficiary
With Contingent Beneficiaries
Office of the New York State Comptroller
·~
RS 5127
New York State and Local Retirement System
(Rev. 9/14)
Employees' Retirement System
Police and Fire Retirement System
THIS FORM MUST BE SIGNED, NOTARIZED AND FILED WITH THE
110 State Street, Albany, New York 12244·0001
RETIREMENT SYSTEM PRIOR TOYOUR DEATH TO BE EFFECTIVE.
Please PRINT clearly, using only blue or black ink.
Member/Pensioner Information
Registration/Retirement Number: - - - - - - - - - - - -
Last 4 Digits of Social Security Number• _ _ _ _ _ _ _ _ __
Name: ______________________________________
Former Name: ________________________
Home Address:
City, State, Zip Code: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Date of B i r t h : - - - - - - - - - - - - - - - - - -
Telephone Number: ________________________
Email Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
I
Employed
By'
I
Employer Address'
IMPORTANT INFORMATION REGARDING THIS FORM
• If you find this form is not suited to the type of designation you prefer
please advise the Retirement System. In the meantime, for your
protection and the protection of your beneficiary(les), you should
make an interim designation using this form. If you wish to designate
more beneficiaries than this form allows or to designate a Trust,
Guardianship or payment under the Uniform Transfers to Minors
Act please contact the Retirement System for the appropriate form.
• Attachments to your beneficiary form are unacceptable.
• New beneficiary forms filed will supersede any previous designation.
Therefore, if you want to add or delete a beneficiary, for example a
new child, you must include on the new form all beneficiaries you
wish to designate.
• The same person or persons cannot be designated as both primary
and contingent beneficiaries. We make payment to a contingent
beneficiary(ies) only if all primary beneficiary(ies) die before you do.
• If you wish to have these benefits distributed through your estate,
you should name "my estate" as beneficiary. Your estate can be
named as either primary or contingent beneficiary. However, if you
name your estate as primary beneficiary, you may not name any
contingent beneficiary.
• This form is for designating beneficiaries to receive your ordinary
death or post retirement death benefit. You may not designate
beneficiaries to receive accidental death benefits. The beneficiaries
entitled to receive accidental death benefits are mandated by statute.
Make sure that you:
• Complete all requested Information.
• Sign and date the form.
• Have the form notarized, making sure the notary has entered
the date his or her commission expires.
• Mall your completed form to:
New York State and Local Retirement System
Member & Employer Services
Registration - Mall Drop 5-6
11 0 State Street
Albany, NY 12244-0001
PERSONAL PRIVACY PROTECTION LAW
In accordance with the Personal Privacy Protection Law you are hereby advised that
pursuant to the Retirement and Social Security Law, the Retirement System Is required to
maintain records. The records are necessary to determine eligibility for and to calculate
benefits. Failure to provide Information may result in the System's lnabilily to pay
benefits the way you prefer. The System may provide certain Information to participating
employers. The official responsible for maintaining these records Is the Director of
Member
&
Employer Services, New York State and Local Retirement Syslems, Albany, NY
12244. For questions concerning this form, please call1·866·805·0990 or 518·474·n36.
• SOCIAL SECURITY DISCLOSURE REQUIREMENT
In accordance with the Federal Privacy Act of 1974, you are hereby advised that
disclosure of the Social Security Account Number Is mandatory pursuant to sections
11, 31, 34 and 334 of the Retirement and Social Security Law. The number will be used
In Identifying retirement records and In the administration of the Retirement System.
Please go to the reverse side of this form to designate beneficiaries, sign and date the form, and
have the form notarized.
AS 5127
(front)
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