Designation Of Beneficiary Form - Vermont Retirement Systems (Page 2 of 2) in pdf

INSTRUCTIONS

(You must type or print the appropriate information in ink or ball point pen.)

Participation in the Vermont Retirement Systems provides valuable benefits payable at your death. You may designate

the beneficiary (ies) to receive those appropriate benefits by completing this form.

SYSTEM:

Your first entry will be to indicate which retirement system you are a member of by marking “X” in the appropriate

box following ‘TO: Board of Trustees’.

PRIMARY/CONTINGENT BENEFICIARY(IES):

The Primary or Joint-Primary beneficiaries share and share alike. A Contingent beneficiary(ies) will receive benefits, if

payable, in the event the primary beneficiary is deceased. In the event both primary and contingent beneficiaries

are deceased, any residual benefits are payable to your estate.

BOX 1 is to be used for the purpose of nominating a primary beneficiary for benefits payable if death occurs prior to

retirement and while a member of the retirement system.

∗ Benefits consist of: 1) a lump sum refund of accumulated contributions and interest or 2) an eligible dependent

beneficiary may receive a survivorship retirement allowance in lieu of a refund as provided under the appropriate statute.

Please note that only one (1) dependent beneficiary may be named as “PRIMARY” in order to receive a

survivorship retirement allowance in the event of your death as an active employee. If more than one

“PRIMARY” beneficiary is named, and you die as an active employee, your accumulated contributions and

interest will be divided up amongst the named primary beneficiaries.

BOX 2 is optional and is used to name a contingent beneficiary(ies).

NOTE: ● A member may nominate any person or persons, institution, trust, estate, guardian for minor children, etc., as

primary or contingent beneficiary. ● If multiple primary or contingent beneficiaries are named, it is to be understood that

the beneficiaries still living at the death of the member will share equally in the distribution of a lump sum refund. ● A

divorce does not automatically revoke a former spouse as beneficiary.

MULTIPLE BENEFICIARIES:

If you require space for more beneficiaries than the form has available:

1. Number this form page “1” in the upper right hand corner.

2. Use a second form, numbering it page “2” and complete all entries.

3. Continue for as many pages as required to list all beneficiaries.

4. On page “1”, enter the highest page number used and a count of your total beneficiaries designated. (This is to

ensure completeness of the document).

5. Staple the pages together in the upper left corner.

CHANGE OF BENEFICIARY:

A member may at any time change beneficiary designation. The change must be filed in accordance with regulations by

the Board of Trustees and it will supersede any previous designation on file with the system.

MEMBER’S SIGNATURE:

This form must be signed by the member in the presence of a Notary Public in order to be accepted by this office.

NOTARY PUBLIC:

This form must be duly notarized in order for the retirement system to legally record your beneficiary designation.

Designation of Beneficiary Form Revised: 3/31/08

Designation Of Beneficiary Form - Vermont Retirement Systems Page 2