BENEFICIARY DESIGNATION FOR
Clear Form
MEMBER/RETIREE/PARTICIPANT
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PO Box 48380 Olympia, WA 98504-8380
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Toll Free: 800.547.6657
Olympia Area: 360.664.7000
TTY: 711
Important:
Please return this form to DRS, not your employer.
If you make an error on this form, simply correct it and initial beside the correction.
Select the system(s) to which you would like your beneficiary(ies) applied. If you are a member of multiple retirement
plans, you are able to designate the same beneficiaries to all of those plans by checking the boxes.
c
Deferred Compensation Program (DCP)
c
Law Enforcement Officers’ & Fire Fighters’
c
School Employees’ (SERS)
(LEOFF)
Judicial (JRS)
State Patrol (WSPRS)
c
c
c
Public Employees’ (PERS)
Judicial Retirement Account (JRA)
Teachers’ (TRS)
c
c
Public Safety Employees’ (PSERS)
c
My Personal Information
Name (Last, First, Middle)
Social Security Number
Mailing Address
City
State
ZIP
Phone Number
Alternate Phone Number
Email Address
Beneficiary Designation
– Designate at least one primary beneficiary; do not designate yourself. See the back of
this form for beneficiary definitions. If you make a mistake, initial next to your actual designation. If you select more than
one primary beneficiary or more than one contingent beneficiary, the total percentage(s) for each type of beneficiary must
add up to 100%. Use whole numbers (for example, 50% and 50%, or 66% and 34%).
Last Name, First
Relationship
Beneficiary Mailing Address
c
Spouse
c
X
Primary
Social Security Number
Date of Birth
City
State
ZIP
______%
c
Other __________
Last Name, First
Relationship
Beneficiary Mailing Address
c
Primary
c
Spouse
c
Contingent
Social Security Number
Date of Birth
City
State
ZIP
c
Other __________
______%
Last Name, First
Relationship
Beneficiary Mailing Address
c
Primary
c
Spouse
c
Contingent
Social Security Number
Date of Birth
City
State
ZIP
c
Other __________
______%
Last Name, First
Relationship
Beneficiary Mailing Address
c
Primary
c
Spouse
Social Security Number
Date of Birth
City
State
ZIP
c
Contingent
c
Other __________
______%
If you need to list more than four beneficiaries, please complete the same information above on a separate piece
of paper, sign and date it, attach it and return it along with this form. Do not use the section on back for additional
beneficiaries.
*DRSMS100*
DRS MS 100 (R 10/14)
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