Rejection Of Joint And Survivor Benefit Upon Retirement Form
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1Teamsters Joint Council No. 83 of Virginia
Health & Welfare and Pension Funds
8814 Fargo Road ∙ Suite 200 ∙ Richmond, VA 23229
Phone (804) 282-3131 ∙ 800-852-0806 ∙ Fax (804) 288-3530
Rejection of Joint and Survivor Benefit upon retirement
Must be filled out in front of a Notary Public
You have a right to take 30 days to consider the form of benefit.
Retiree's name __________________________________________
SSN
______________________
Spouse’s name __________________________________________
SSN
______________________
Spouse's date of birth
_____________________
I DO NOT WISH TO RECEIVE MY PENSION BENEFITS IN THE FORM OF A JOINT AND SURVIVOR
BENEFIT. I understand that rejecting the Joint and Survivor Benefit means no benefits will be paid to my spouse
from the Pension Plan after my death, unless benefits are payable under another provision of the Plan.
CHECK ONE BOX:
I hereby swear that the person co-signing this form below is my current legal spouse.
I hereby swear that I am unable to locate my spouse (SUBMIT ADDITIONAL PROOF).
I hereby swear that I am not legally married at this time.
Retiree's Signature ________________________________________________
Date ____________________
I SWEAR THAT I AM THE LEGAL SPOUSE OF THE ABOVE PARTICIPANT. I hereby consent to my spouse’s
rejection of the Joint and Survivor Benefit. I understand that as a result, I will not be paid any benefits from the
Pension Plan after my spouse’s death, unless benefits are payable under another provision of the Plan. I further
understand that because of this rejection, the monthly pension paid to my spouse while he or she is living will be
higher than it would be if I had the survivor protection.
Spouse’s signature ________________________________________________
Date ____________________
This section must be completed by the Notary Public who witnesses the above signature.
State of __________________________________
County of _____________________________
Acknowledged before me this
__________________ day of __________________
20_________
Notary Public ____________________________________________________________________
My commission expires _____________________
My registration number: __________________
Required for the state of Virginia
THIS FORM MUST BE SIGNED AND NOTARIZED DURING THE 90-DAY PERIOD
IMMEDIATELY PRIOR TO THE DATE YOUR PENSION PAYMENTS BEGIN.
Upd. 6/23/2014
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