Form Ppf 170 - Option And Beneficiary Selection Form (Page 2 of 2) in pdf

– Option and Beneficiary Selection Form

New York City Police Pension Fund

First name: _________________ Last name: __________________________ Pension #: ____________

B. Select your beneficiary (or beneficiaries):

 Options that allow multiple beneficiaries who may be changed at any time: Option 1 –

Return of Pension Reserve (Tier I members only); Option 4 – Lump Sum; Option 5: 5-year

Certain; Option 6: 10-year Certain. If you designate more than one beneficiary, indicate the

percentage each beneficiary is to receive. If you wish to name more than three beneficiaries,

copy this page and attach the copy.

 Options that allow a single beneficiary who may never be changed (note: beneficiary date of

birth proof is required for any of these options): Option 2; Option 3; Option 4 – Annuity;

Option 4 – 2: 100% Joint & Survivor with Pop-up; Option 4 – 3: 50% Joint & Survivor with

Pop-up; Option 4 – 4: Annuity with Pop-up.

Beneficiary designation (percentages must total 100% -- please print:



Beneficiary 1 ...............................

Percentage

= ____ %

First name: _______________________ MI: ___ Last name: ________________________________

Date of birth: ____/____/_______ Relationship: _____________ Social Sec. #: ______-____-_______

Street address: ______________________________________________________________________

City: _____________________________________ State: ______ Zip code: ___________________



Beneficiary 2 .............................. Percentage = ____ %

First name: ______________________ MI:___ Last name: _________________________________

Date of birth: ____/____/_______ Relationship: _____________ Social Sec. #: ______-____-_______

Street address: ______________________________________________________________________

City: ____________________________________ State: ______ Zip code: ___________________



Beneficiary 3 .............................. Percentage = ____ %

First name: ______________________ MI:___ Last name: _________________________________

Date of birth: ____/____/_______ Relationship: _____________ Social Sec. #: ______-____-_______

Street address: ______________________________________________________________________

City: ______________________________________ State: _____ Zip code: ____________________

Signature: ____________________________________________ Date: ____/____/_______

Notarization:

[Notarization required if this form is mailed to NYCPPF]

State of __________ County of _______________________

On this _____ day of ___________________, 20 ___ before me

Personally appeared ____________________________________ ,

to me known and known to me to be the same person described herein

and who executed the foregoing instrument, and (s)he duly acknowledged

that (s)he executed the same.

Notary Public signature: ____________________________________

Please affix stamp or seal

Pension Payroll

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PPF 170

Form Ppf 170 - Option And Beneficiary Selection Form Page 2

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