Form Drs Ms 100 (Rev 2/13) - Member/retiree/participant Beneficiary Designation Form Page 2
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3Beneficiary Designation for One-Time Duty-Related Death Benefit
c I designate the Beneficiary(ies) listed on page one.
Designation
Beneficiary Information
Relationship
Full Name of Person, Estate, Trust or Organization
Mailing Address
Must check one
c
Primary
Social Security Number
Date of Birth
City
State
ZIP
c
Contingent
Full Name of Person, Estate, Trust or Organization
Mailing Address
Must check one
c
Primary
Social Security Number
Date of Birth
City
State
ZIP
c
Contingent
Full Name of Person, Estate, Trust or Organization
Mailing Address
Must check one
c
Primary
Social Security Number
Date of Birth
City
State
ZIP
c
Contingent
Signature Required –
MUST complete in full.
I, __________________________________________________,
direct that any monies related to my
(print name)
account, unless otherwise specified or required by law, will be paid in equal shares to any primary beneficiaries named
on this form who survive me, but if none survive, such monies will be paid in equal shares to any contingent beneficiaries
named on this form who survive me. I hereby certify that I have read and understand the instructions to this form and that
all of the information I have entered on this form is true and complete. Submission of this document revokes any prior
designations that I have made.
Signature
Date
If you have insurance coverage through the Washington State Public Employees Benefits Board (PEBB), we may share
your information with PEBB to better serve you.
Department of Retirement Systems (DRS) requires that you provide your Social Security number for this form.
•
DRS will use your Social Security number as a reference number and to ensure that any funds disbursed under
your account are correctly reported to the IRS.
•
DRS will not disclose your Social Security number unless required by law.
•
Internal Revenue Code Sections 6041(a) and 6109 allow DRS to request your Social Security number.
DRS MS 100 (R 2/13)
Page 2 of 3
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