Texas Application For Payee Identification Number Page 3

Download a blank fillable Texas Application For Payee Identification Number 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 Texas Application For Payee Identification Number 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.

11410 SW 68th Parkway, Tigard OR 97223

Mailing Address – PO Box 23700, Tigard OR 97281-3700

Phone – 503-598-7377 toll free – 888-320-7377

2103

Fax – 503-598-0561 website –

Alternate Payee Benefit Application

This form is strictly for the Tier One/Tier Two program. Call PERS or visit our website if this is not the form you need.

Section A: Applicant information

(Type or print clearly in dark ink. Illegible forms could be returned to you, which could delay your request.)

First name

Last name

PERS ID number

Former name (if different from present name)

Social Security number*

Mailing address (street or PO box)

Date of birth (mm-dd-yyyy)

City

State

Zip

Country

Day phone number

Beneﬁ t election effective date

Section B:

I request that my benefit will be effective the first day of the month and year I have entered below for the option I checked in Section

D. I understand my benefit is effective the later of the first of the month following the month in which my application is received, the

first of the month in which my ex-spouse is eligible to retire, or the date entered below.

Year

1st day of month

Section C: Ex-spouse information

First name

Last name

Social Security number

Effective date of divorce/annulment/separation

Date of decree amendments (if any)

Section D: Beneﬁ t options (Select one of the ﬁ ve beneﬁ t options.)

Option 1

Lump-Sum Option 1**

(no beneﬁ ciary)

Refund Annuity (beneﬁ ciary need not be a person) Total Lump-Sum** payout of both employee dollars and any employer

dollars that may be due (no beneﬁ ciary provisions).

15-Year Certain (beneﬁ ciary need not be a person)

** Your balance and any employer dollars that may be due can be paid in full or in up to five annual installments. Indicate the percentage to be paid

each year. The smallest percentage is 1 percent, and the percentage needs to be in whole numbers, not fractions. If you elect to be paid in full,

enter 100 by the first percentage. When you die, your remaining account balance will be paid to your beneficiary(ies).

1st ___________ % + 2nd __________% + 3rd__________% + 4th__________% + 5th__________% = Total _________

Section E: Residency certiﬁ cation (required)

Select one:

 I am a resident of the state of Oregon; therefore, payments made to me as a result of this beneﬁ t application will be subject to

Oregon personal income tax.

 I am not a resident of the state of Oregon; therefore, payments made to me as a result of this beneﬁ t application will not be subject

to Oregon personal income tax.

I hereby declare that the above statement is true to the best of my knowledge and belief, and I understand it is subject to penalty for

perjury.

Applicant signature (do not print) __________________________________________________ Date __________________________

Section F: Applicant signature (required)

Sign and date for the entire application. (Must be witnessed by a notary public.)

Applicant signature (do not print) ___________________________________________________

Date __________________________

Notary Public

State of

County of

Signed before me on:

Applicant’s name

By (notary’s signature)

My commission expires

* Providing your Social Security number (SSN) is voluntary. It will be used for conﬁ rmation purposes. If you choose not to supply your SSN, it may take PERS staff longer to process your form.

In compliance with the Americans with Disabilities Act, PERS will provide help filling out this form upon request. You may request help by calling 503-598-7377, toll free 888-320-7377, or TTY 503-603-7766.

ORS: 238.465 Form #459-007 (4/16/2014) SL3 IIM Code: 2103

Print Form

Clear Fields