Application For Membership/initial Beneficiary Designation

*B0$JRS*

APPLICATION FOR MEMBERSHIP/INITIAL BENEFICIARY DESIGNATION - JRS

1. Please print or type clearly.

2. Send this form to your Human Resources or Payroll office. Do not send to Judicial Retirement System

(JRS).

SECTION 1 - MEMBER INFORMATION

___________________________________________________

Name:

SSN:

(Last)

(First)

(MI)

(Maiden)

Mailing Address: _______________________________________________________________________________________________

(Street)

(City)

(State)

(Zip Code)

______/______/______

Date of Birth:

Gender:

Male

Female

Daytime Phone No: (_______) ________________

Current Position (Circle One)

Superior Court Judge

District Attorney

Juvenile Court Judge

Solicitor

State Court Judge

Law Department/Legislative Counsel

Previous Retirement Plan (Circle all that apply):

ERS

TJ&S

SCJ

SECTION 2 - DESIGNATION OF BENEFICIARY

You should designate a Primary and a Contingent Beneficiary. The Contingent Beneficiary is valid only if all of the Primary

Beneficiaries are deceased at the time of your death. If naming the Estate as beneficiary, please write “Estate” and do NOT

include another individual’s name as a part of the Estate designation. You may designate joint beneficiaries who will share

and share alike if the following procedure is used.

1. List all beneficiaries under the Primary Beneficiary space (or use a separate sheet of paper and attach to this form).

2. If you wish for joint beneficiaries to share equally, then write in the margin - “To Share and Share Alike.” If you

wish for joint beneficiaires to receive varying portions, then write the percentage that you wish for them to re-

ceive next to each name. The total amount designated must equal 100%.

Primary Beneficiary ___________________________________________ Relationship___________________________________

Address___________________________________________________________________ Date of Birth_______/______/_______

Primary Beneficiary ___________________________________________ Relationship___________________________________

Address___________________________________________________________________ Date of Birth_______/______/_______

Contingent Beneficiary ___________________________________________ Relationship________________________________

Address___________________________________________________________________ Date of Birth_______/______/_______

Contingent Beneficiary ___________________________________________ Relationship________________________________

Address___________________________________________________________________ Date of Birth_______/______/_______

Member Signature: ________________________________________________

Date:______________________________

SECTION 3 - PERSONNEL/PAYROLL USE ONLY

Hire Date:_________/_________/________ County:________________________________ Monthly Salary:___________________

AgencyTelephone #: (________) - _____________________________ Email Address: _____________________________________

HR or Payroll Officer Signature: _______________________________________________ Date: _________/_________/_________

B0JRS 06/2009

(404) 350-6300 • (800) 805-4609 •

Application For Membership/initial Beneficiary Designation - Jrs Form

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