Refund Beneficiary Designation Form For Retirees printable pdf download

Department of Technology, Management & Budget

Office of Retirement Services

(800) 381-5111

P.O. Box 30171

Lansing MI 48909-7671

Refund Beneficiary Designation

For Retirees

MEMBER’S NAME (LAST, FIRST, M.I.)

MEMBER ID OR SSN

MAILING ADDRESS

HOME TELEPHONE

(

)

CITY, STATE, ZIP CODE

RETIREMENT SYSTEM (CHECK ONE)

PUBLIC SCHOOL EMPLOYEES

STATE POLICE

STATE EMPLOYEES

JUDGES

Changing Your Refund Beneficiary

Use this form to change your retirement refund beneficiary. At your death, if there is no survivor pension

beneficiary eligible to receive an ongoing pension benefit, the person(s) named below will receive the balance

of any personal contributions not used to fund your pension benefit.

You can designate one or more people as your refund beneficiar(y)ies. Attach another sheet of paper for

additional names. If you do not name a beneficiary or you write “NONE” on the beneficiary name line, upon

your death, any refund due will be paid to your estate or the legal representative of your estate.

NOTE: This refund beneficiary designation remains in effect until you submit a new Refund Beneficiary

Designation to ORS.

Refund Beneficiary Name: ______________________________________

Relationship: _________________________

Beneficiary’s SSN: _________________________ Birth Date: ________________________

Male

Female

Refund Beneficiary Name: ______________________________________

Relationship: _________________________

Beneficiary’s SSN: _________________________ Birth Date: ________________________

Male

Female

Your signature must be notarized below. Do not sign until you are in front of a Notary Public.

STOP

Retiree Signature

I understand the most current refund beneficiary designation on file with ORS at the time of my death establishes the

recipient(s) of my refund payment, if any. I intend for this refund beneficiary designation to supersede all previous filings

with ORS.

RETIREE SIGNATURE

DATE

Notary Public:

Subscribed and sworn to before me this ______ day of _____________________, _________

County of ______________________, State of _________________

My commission expires ________________________, __________

Notary Signature ______________________________________

Return your completed form to: ORS, PO Box 30171, Lansing MI 48909-7671

Keep a copy for your records.

R0748X (Rev. 4/2010)

Authority, as amended: 1980 P.A. 300; 1943 P.A. 240; 1986 P.A. 182; 1992 P.A. 234

Refund Beneficiary Designation Form For Retirees

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