Form Rs-02 - Post-Retirement Beneficiary Renunciation Of Survivorship Pension

Download a blank fillable Form Rs-02 - Post-Retirement Beneficiary Renunciation Of Survivorship Pension in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Rs-02 - Post-Retirement Beneficiary Renunciation Of Survivorship Pension with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

New Hampshire Retirement System

54 Regional Drive, Concord, NH 03301

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

Website: - Email:

POST- RETIREMENT BENEFICIARY RENUNCIATION OF SURVIVORSHIP PENSION

The beneficiary of a retiree who elected Survivorship Option 2, 3, or 4 at retirement, and designated a single beneficiary, may

choose to voluntarily renounce any and all entitlement to a lifetime survivorship pension, provided the renunciation occurs

prior to the retiree’s death.

SECTION I - TO BE COMPLETED BY THE BENEFICIARY (Print)

Beneficiary Name:

Beneficiary Social Security #:

Beneficiary Phone:

Beneficiary Mailing Address:

Retiree Name:

Retiree Social Security #:

SECTION II - RENUNCIATION OF SURVIVORSHIP PENSION

I understand that I am the survivorship beneficiary of the above named member of the New Hampshire Retirement System (NHRS)

and, as a result, I may be entitled to a lifetime survivorship pension from the NHRS. I also understand that under RSA 100-A:13, II(b),

I may renounce any and all entitlement I may have to this survivorship pension.

I hereby voluntarily renounce all right to the lifetime survivorship pension of $______________ per month that I would otherwise be

entitled to receive upon the death of the above named NHRS retiree.

I understand that this renunciation is complete, permanent, and irrevocable, and will take effect on the first day of the month following

receipt of this acknowledged form by NHRS.

SECTION III - SIGNATURE AND ACKNOWLEDGMENT

Beneficiary’s Name ___________________________________________ Beneficiary’s Address

_______________________________________________________

Beneficiary’s Signature

Date

Social Security #

______________________________________________

_______/_______/__________

_________-______-_________

Month

Day

Year

State of _____________________________________________________________ County of _____________________________________________________

The foregoing instrument was acknowledged before me this

___________________

_________________________________________________________________

Date

Beneficiary’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-02

Revised 11/2010