Form Eb-0791-0812 - Designation Of Beneficiary - 2012 Page 2
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3State of New Jersey • Department of the Treasury
DIVISION OF PENSIONS & BENEFITS — BENEFICIARY SERVICES
P.O. Box 295, Trenton, NJ 08625-0295
DESIGNATION OF BENEFICIARY
Alternate Benefi t Program/Defi ned Contribution Retirement Program
Please read and follow the instructions before completing this form
1. Contribution Program: (check one)
Alternate Benefi t Program
Defi ned Contribution Program
2. Employment Status: (check one)
Active
Retired
3. Print Your Full Name: ________________________________________________________________
4. Birth Date: _____/_____/______
5. Social Security Number: ______________________________
6. Location Name:_____________________________________________________________________
7. GROUP LIFE INSURANCE (Active and Retired)
Primary Benefi ciary(ies)
Benefi ciary Name
Relationship
Social Security #
Birth Date
1. ____________________________________
_________________
_________________
_____/_____/______
Address________________________________________________________________________________________
2. ____________________________________
_________________
_________________
_____/_____/______
Address________________________________________________________________________________________
3. ____________________________________
_________________
_________________
_____/_____/______
Address________________________________________________________________________________________
Contingent Benefi ciary(ies) - If primary benefi ciary is not living at my death, payment is to be made to:
Benefi ciary Name
Relationship
Social Security #
Birth Date
1. ____________________________________
_________________
_________________
_____/_____/______
Address________________________________________________________________________________________
2. ____________________________________
_________________
_________________
_____/_____/______
Address________________________________________________________________________________________
3. ____________________________________
_________________
_________________
_____/_____/______
Address________________________________________________________________________________________
8. SIGNATURE OF MEMBER_________________________________________________ Date
_____/_____/______
Mailing Address_________________________________________________________________________________
Daytime Telephone No. ( _________ ) ________________________________________
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