Designation Of Beneficiary For Retirees Who Elected A Lump Sum Option Form
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1
2RMS-5 (2/10)
OFFICE SERVICES ONLY
NEW YORK STATE TEACHERS’ RETIREMENT SYSTEM
10 Corporate Woods Drive, Albany, NY 12211-2395
DESIGNATION OF BENEFICIARY FOR RETIREES
ELECTING A LUMP SUM OPTION
Last Name
First Name
M.I.
Social Security Number
Street Address
EmplID
City, State, Zip
Is this your permanent address to be
Phone Number
p
p
Yes
No
used by the System?
I, THE UNDERSIGNED, REVOKING ALL FORMER DESIGNATIONS MADE BY ME PURSUANT TO A LUMP SUM OPTION, HERE-
BY DIRECT THE NYS TEACHERS’ RETIREMENT SYSTEM, IN THE EVENT OF MY DEATH, TO PAY ANY BENEFIT DUE TO THE
BENEFICIARY(IES) NAMED BELOW.
P
B
– If more than one primary beneficiary is named, the share of any beneficiary who dies before me shall be
rimary
eneficiaries
divided equally among the surviving primary beneficiaries.
p
p
p
p
Name _______________________________________________ M
F
Name _____________________________________________ M
F
Date of Birth ___________________ Relationship _______________________
Date of Birth _____________________ Relationship ___________________
Social Security # ____________________________________________________
Social Security # __________________________________________________
Street ______________________________________________________________
Street ____________________________________________________________
City, State, Zip ______________________________________________________
City, State, Zip ____________________________________________________
p
p
p
p
Name _______________________________________________ M
F
Name ______________________________________________ M
F
Date of Birth ___________________ Relationship _______________________
Date of Birth _____________________ Relationship ___________________
Social Security # ____________________________________________________
Social Security # __________________________________________________
Street ______________________________________________________________
Street ____________________________________________________________
City, State, Zip ______________________________________________________
City, State, Zip ____________________________________________________
c
B
– Should I survive my primary beneficiary or beneficiaries, any benefit payable at my death shall be paid in
ontingent
eneficiaries
equal shares, unless otherwise stipulated, to the surviving contingent beneficiary or beneficiaries. Should I survive all named
beneficiaries, any payment shall be paid to my estate.
p
p
p
p
Name _______________________________________________ M
F
Name ______________________________________________ M
F
Date of Birth ___________________ Relationship _______________________
Date of Birth _____________________ Relationship ___________________
Social Security # ____________________________________________________
Social Security # __________________________________________________
Street ______________________________________________________________
Street ____________________________________________________________
City, State, Zip ______________________________________________________
City, State, Zip ____________________________________________________
Signature of Retiree:
(must be notarized to be valid)
State of ____________________________________, County of ____________________________________________________________________
On this _______ day of ___________________ in the year __________ before me, the undersigned, a Notary Public in and for said
State, personally appear ______________________________________________ , personally known to me or proved to me on the basis
of satisfactory evidence to be the individual whose name is subscribed to the within instrument, and acknowledged to me that
he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person
upon behalf of which the individual acted, executed the instrument.
Signature of Notary: _________________________________________________
Expiration Date: _________________________
Please review the “INSTRUCTIONS FOR DESIGNATING A BENEFICIARY UNDER A LUMP SUM OPTION” and checklist on the reverse.
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