Designation Of Beneficiary For Retirees Who Elected A Guarantee Period Option Form
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1
2RMS-5.3 (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 GUARANTEE OPTION
Last Name
First Name
M.I.
Social Security Number
Street Address
EmplID
City, State, Zip
Is this your permanent address to
Phone Number
p
p
Yes
No
be used by the System?
I, THE UNDERSIGNED, REVOKING ALL FORMER DESIGNATIONS MADE BY ME PURSUANT TO A GUARANTEE OPTION,
HEREBY 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
– My primary beneficiary will receive the same monthly payments I was receiving for the unexpired balance of
rimary
eneficiary
the guarantee period. If I live beyond the guarantee period, all payments will cease at my death. Only one primary beneficiary
may be designated under this option.
p
p
Name ______________________________________________ M
F
Date of Birth _________________ Relationship _______________________
Street _______________________________________________________________
City, State, Zip ____________________________________________________
Social Security # ____________________________________________________
c
B
– If my primary beneficiary predeceases me or begins to receive payments and dies before the guarantee
ontingent
eneficiaries
period expires, the commuted value of any installments due will be paid in a lump sum to my contingent beneficiary or beneficiaries.
If none exist, the commuted value will 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 ____________________________________________________
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 GUARANTEE OPTION” and checklist on the reverse.
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