Designation Of Beneficiary Form
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1
2DESIGNATION OF BENEFICIARY FORM
ARLINGTON COUNTY EMPLOYEES’ RETIREMENT SYSTEM
2100 CLARENDON BOULEVARD – SUITE 511
ARLINGTON, VIRGINIA 22201
TELEPHONES: (703) 228-3500, (800) 818-4910 FAX (703) 228-3265
Email:
benefits@arlingtonva.us
NEW EMPLOYEE
CHANGE IN DESIGNATION
INSTRUCTIONS:
Please complete items 1 through 10, sign and date the form and return to the Retirement
Office. Item 5 is your primary beneficiary. If you wish to designate more that one beneficiary, please skip to
item 10.
1) Member Name (Last)
(First)
(Middle Initial)
2) Member Social Security #
3) Member Date of Birth
4) Member Address
5) Name of Beneficiary
6) Address of Beneficiary
7) Relationship to Member
8) Beneficiary Date of Birth
9) Beneficiary Social Security #
10) In the event the above named beneficiary predeceases me, I designate the following as my beneficiary.
(Also to be used to designate more than one beneficiary. Shares to more than one beneficiary must equal 100%)
Name_________________________________
Social Security # ____________________
%
Beneficiary Date of Birth _________________
Relationship
____________________ Gender _____
Address___________________________________________________________________________________
Name_________________________________
Social Security # ____________________
%
Beneficiary Date of Birth _________________
Relationship
____________________ Gender _____
Address___________________________________________________________________________________
Name_________________________________
Social Security # ____________________
%
Beneficiary Date of Birth _________________
Relationship
____________________ Gender _____
Address___________________________________________________________________________________
I hereby authorize the Arlington County Employees’ Retirement System to make payment to the beneficiary or
beneficiaries whom I have above nominated, and I agree on behalf of myself and my heirs and assigns, that payment so
made shall be a complete discharge of the claim and shall constitute a release of the system from any further obligation of
retirement benefits. I hereby direct that should I survive any or all of the before mentioned beneficiaries, the amount
which otherwise would have been payable to the beneficiary or beneficiaries shall be paid to my estate or to such other
beneficiary or beneficiaries as I shall hereafter nominate, by written designation filed with the Arlington County
Employees' Retirement System. I reserve the right to change the above named beneficiaries without their consent or
notification.
______________________________________
__________________________________________
Date
Signature
Rev. 2/14
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