Rs 5127 - Designation Of Beneficiary With Contingent Beneficiaries Page 2

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To the Comptroller of the State of New York.

Designation of

fr.1.m.ru:¥

Beneficlary(ies). I hereby name the following beneficiary(les) to receive any ordinary death or post retirement death benefit, payable

on my behalf. If I have named more than one beneficiary, it is my intention that those living at the time of my death should share equally any benefit payable.

reserve the right to change this designation at any time.

Name

Male 0Female

Address

Relationship

Birth Date

Telephone Number

Name

Male 0Female

Address

Relationship

Birth Date

Telephone Number

Name

0Male 0Female

Address

Relationship

Birth Date

Telephone Number

Name

Male 0Female

Address

Relationship

Birth Date

Telephone Number

Name

Male 0Female

Address

Relationship

Birth Date

Telephone Number

Name

Male 0Femaie

Address

Relationship

Birth Date

Telephone Number

Designation of Contingent Beneficlary(ies). If all of the designated primary beneficiaries die before I do, any ordinary death or post retirement death benefit

payable on my behalf shall be paid to the following.

If I have named more than one beneficiary, It Is my Intention that those living at the time of my death should

share equally any benefit payable. If I out-live all of these contingent beneficiaries, any benefit payable should be paid to my estate. I reserve the right to change

this designation at any time.

Name

0Maie 0Female

Address

Relationship

Birth Date

Telephone Number

Name

0Male 0Female

Address

Relationship

Birth Date

Telephone Number

Name

0Maie 0Female

Address

Relationship

Birth Date

Telephone Number

Name

Male 0Femaie

Address

Relationship

Birth Date

Telephone Number

This form must be signed, dated and notarized In order to be valid

Member/Pensioner Signature

Date

Acknowledgement To Be Completed by a Notary Public

State of _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Counwof - - - - - - - - - - - - - - - - - - - - - - -

On the _____ day of

in the year

before me, the undersigned, personally appeared

, personally

known to me or proved to me on the basis of satisfactory evidence to be the lndividual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged

to me that he/she/they executed the same in his/her/their capacity(les), and that by his/her/their signature(s) on the instrument, the lndividual(s), or the person upon

behalf of which the individual(s) acted, executed the instrument.

Notary Public Stamp

NOTARY

PUBLIC (Please sign and affix stamp)

RS 5127 (Rev. 9/14)

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