Form Rs 6400 - Retirement Option Election Form For Tier 3, 4, 5 And 6 Ers Members Page 2

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DESIGNATION OF PRIMARY BENEFICIARY(IES)

Use the beneficiary’s given name: Mary Smith NOT Mrs. John Smith. Please print plainly or type.

I hereby name the following beneficiary(ies) to receive any benefit payable on my behalf. If I have named more than one beneficiary, it is my

intention that those living at the time of my death should share equally any benefit payable.

Name ______________________________________________________

Name

______________________________________________________

Relationship _________________________ Birth Date _______________

Relationship

_________________________

Birth Date

_______________

Soc. Sec. No.* _______________________________________ Sex_____

Soc. Sec. No.*

_______________________________________

Sex

_____

Address (Street, City, State, Zip)

___________________________________________________________

Name ______________________________________________________

Relationship _________________________ Birth Date _______________

Soc. Sec. No.* _______________________________________ Sex_____

Address (Street, City, State, Zip)

___________________________________________________________

DESIGNATION OF CONTINGENT BENEFICIARY(IES)

Use the beneficiary’s given name: Mary Smith NOT Mrs. John Smith. Please print plainly or type.

If all the above named beneficiary(ies) die before I do, any benefits payable on my behalf should be paid to the following. If I have named more than

one beneficiary, those living at the time of my death should share any benefit equally.

Name ______________________________________________________

Relationship _________________________ Birth Date _______________

Soc. Sec. No.* _______________________________________ Sex_____

Address (Street, City, State, Zip)

___________________________________________________________

* Social Security Number required. (See statement below.)

Retiree’s Signature (sign name in full)

Acknowledgement To Be Completed by a Notary Public

State of ________________________________________________ County of _________________________________________________

On the ______________ day of _______________________________ in the year ______________________, before me, the undersigned, personally appeared

___________________________________________________ personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s)

whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies) and that by

his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument.

______________________________________________________

NOTARY PUBLIC (Please sign and affix stamp)

Social Security Disclosure Requirement

In accordance with the Federal Privacy Act of 1974, you are hereby advised that disclosure of your Social Security account number is mandatory pursuant to

Sections 11, 34, 311 and 334 of the Retirement and Social Security Law. The number will be used in identifying retirement records and in the administration of

the Retirement System.

Personal Privacy Protection Law

The Retirement System is required by law to maintain records to determine eligibility for and calculate benefits. Failure to provide information may interfere with the

timely payment of benefits. The System may be required to provide certain information to participating employers. The official responsible for record maintenance

is the Director of Member and Employer Services, NYS and Local Retirement System, Albany, NY 12244; call toll-free at 1-866-805-0990 or 518-474-7736 in the

Albany area.

RS 6400 (Rev. 4/13)