Form Rs-03 - Post-Retirement Termination Of Survivorship Option - 2010

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New Hampshire Retirement System

54 Regional Drive, Concord, NH 03301

Phone: (603) 410-3500 - Fax: (603) 410-3501

Website: - Email:

POST-RETIREMENT TERMINATION OF SURVIVORSHIP OPTION

Retirees who elected Survivorship Option 2, 3, or 4 at retirement and divorced after retirement may terminate the Survivorship

Option and beneficiary nomination elected, provided that the former spouse has remarried.

Note: A copy of the divorce decree and a copy of the former spouse’s current marriage certificate, certifying remarriage, must

be submitted with this form.

SECTION I – RETIREE INFORMATION

Retiree’s Name

Retiree’s Address

Retiree’s Social Security #

SECTION II – RETIREE’S FORMER SPOUSE INFORMATION

Name of Former Spouse

Social Security # of Former Spouse

SECTION III – DESIGNATION OF BENEFICIARY(IES)

I designate the following person(s), estate, or trust to receive any lump sum refund of undistributed, accumulated contributions which may be due

upon my death after retirement. To designate additional beneficiaries, initial here _______ and attach signed supplemental information to this

form. The sum of the distribution percentages must equal 100%.

Distribution

Beneficiary

Relationship

Beneficiary Name

Beneficiary Address

Percentage

Social Security #

Date of Birth

to Member

SECTION IV – RETIREE’S SIGNATURE AND ACKNOWLEDGMENT

I understand that the pension I am receiving at this time shall be converted to the retirement pension that would have been payable had I not

elected the Survivorship Option at the time of retirement, and that any supplemental or cost-of-living allowances already granted shall remain in

effect and shall not be adjusted. I understand that the termination of a Survivorship Option may occur only if it is not in conflict with any

Qualified Domestic Relations Order (QDRO). I understand that the change in the retirement pension will be effective the first day of the month

following receipt of this acknowledged form by the NHRS.

Retiree’s Name _____________________________________________ Retiree’s Address

______________________________________________________________

Retiree’s Signature

_______________________________________________

Date

_______/_______/__________

Social Security #

__________-________-___________

Month

Day

Year

State of _____________________________________________________________ County of _______________________________________________________

The foregoing instrument was acknowledged before me this

___________________

___________________________________________________________________

Date

Retiree’s Name

________________________________________________________ ________________________________________________

______________

Signature of Person Taking Acknowledgment

Title (Notary Public or Justice of the Peace)

Expiration Date

Affix Seal

The New Hampshire Retirement System (NHRS) is governed by New Hampshire RSA 100-A, rules, regulations, and Federal laws including the Internal Revenue Code. NHRS also

implements policies adopted by the Board of Trustees. These laws, rules, regulations, and policies are subject to change. Even though the goal of NHRS is to provide information that is

current, correct, and complete, NHRS does not make any representation or warranty as to the current applicability, accuracy, or completeness of any information provided. The information

herein is intended to provide general information only, and should not be construed as a legal opinion or as legal advice. Members are encouraged to address specific questions regarding

NHRS with an NHRS representative. In the event of any conflict between the information herein and the laws, rules, and regulations which govern NHRS, the laws, rules, and regulations

shall prevail.

RS-03

Revised 11/2010