Survivor Beneficiary Designation Form - Public Employees' Retirement System Of Nevada
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2Public Employees’ Retirement System of Nevada
693 W. Nye Lane, Carson City, NV 89703 - (775) 687-4200 - Fax (775) 687-5131
5820 S. Eastern Ave., Suite 220, Las Vegas, NV 89119 - (702) 486-3900 - Fax (702) 678-6934
Toll Free: (866) 473-7768
SURVIVOR BENEFICIARY DESIGNATION
**THIS FORM SUPERSEDES ALL PRIOR BENEFICIARY DESIGNATIONS**
Name Change Yes
No
Member Information
If Yes, Former Name: ___________________________
Name:________________________________________Social Security Number:_____________________ Employer: _________________________
Address:_____________________________________________________________City, State, Zip:________________________________________
Home Phone:_____________________________Work Phone:________________________________Birth Date:_____________________________
A spouse or registered domestic partner is a member’s primary beneficiary under NRS 286.674 and may be
Family Beneficiary Information.
eligible to receive a lifetime benefit in the event of the member’s death prior to retirement. If a monthly benefit is not available, the spouse or
registered domestic partner may be eligible to receive a one-time lump-sum payment of any existing member contributions in the System. Children
under age 18 may be eligible to receive a limited benefit.
Name of Spouse or Registered Domestic Partner:__________________________Social Security Number:________________Birth Date:__________
List all unmarried children (biological or legally adopted) under age 18. (Attach separate sheet if necessary.)
Name:____________________________________________Social Security Number:_____________________Birth Date_______________M F
Name:____________________________________________Social Security Number:_____________________Birth Date_______________M F
Name:____________________________________________Social Security Number:_____________________Birth Date_______________M F
Survivor Beneficiary Designation
. This designation is valid only upon the member establishing eligibility for survivor benefits pursuant to NRS
286.672 and 286.6767. All members of the System should list one person as the Survivor Beneficiary (not a spouse or registered domestic
partner, trust or charitable organization) to receive a lifetime benefit in the event of the member’s death or member and spouse’s or
registered domestic partner’s simultaneous death prior to retirement. Additional Payees may be designated to split the payment with the
Survivor Beneficiary by percentage. Monthly payments to Additional Payees cease upon the death of the designated Survivor Beneficiary. If
a monthly payment is not available and no spouse or registered domestic partner exists, then the Survivor Beneficiary and Additional Payees
may be eligible to split, by percentage designated, a one-time, lump-sum payment of any existing member contributions in the System.
Survivor Beneficiary: (If you do not wish to provide a lifetime benefit for Survivor Beneficiary/Additional Payees, indicate NONE.)
Name:_____________________________________________SS#______________________Birth Date:_________________ M F
Address:______________________________________________City, State, Zip:____________________________________________
*
Percent
Additional Payees: (Attach separate sheet, if necessary)
Name:_______________________________________________SS#_____________________Birth Date:__________________ M F
Address:________________________________________________City, State, Zip:___________________________________________
*
Percent
Name:_______________________________________________SS#_____________________Birth Date:__________________ M F
Address:________________________________________________City, State, Zip:___________________________________________
*
Percent
Name:_______________________________________________SS#_____________________Birth Date:__________________ M F
Address:_______________________________________________City, State, Zip:____________________________________________
*
Percent
*Survivor Beneficiary & Additional Payee Percentages must be whole numbers and total 100% when added together
TOTAL PERCENTAGES FOR SURVIVOR BENEFICIARY + ALL ADDITIONAL PAYEES =
Total %
Tertiary Beneficiary Designation
. The tertiary beneficiary may be eligible to receive a one-time lump-sum payment of any existing member
contributions in the System when there is no spouse or registered domestic partner and no Survivor Beneficiary/Additional Payee designated or living
and no minor children/student payments are being made by the System. If more than one person is listed, the payment will be split equally unless
otherwise stated by the member. Attach a separate sheet if necessary.
Name:________________________________________________SS#________________________Birth Date:___________________ M F
Address:_________________________________________________City, State, Zip:______________________________________________
Name:________________________________________________SS#________________________Birth Date:___________________ M F
Address:_________________________________________________City, State, Zip:______________________________________________
For PERS Use - Date Received
I understand that the information designated on this form supercedes all prior Beneficiary
Designations that I have submitted on other forms, and that this information only affects records with
the Public Employees’ Retirement System.
Member Signature:___________________________________________Date:_______________________
Rev. 12/09
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