Preretirement Survivor Benefit Beneficiary Designation Form For Unmarried Participants (Page 2 of 2) in pdf

IV. Beneficiary Designation

I have read the Preretirement Survivor Benefit information

(and in that event, payment will be made to my spouse).

provided on this form and understand that if I die before my

If no beneficiary is designated, a Preretirement Survivor

pension payments begin and after meeting the requirements

Benefit will not be paid. I also understand that should

for vesting, a Preretirement Survivor Benefit will be paid by

I marry at some future date, the beneficiary designation

the Pension Plan to the individual(s) I have designated on

I have made on this form automatically will be revoked

this form.

and my spouse will become entitled to the Preretirement

I hereby revoke any prior Preretirement Survivor Benefit

Survivor Benefit.

designation I may have made. I understand that I reserve

I hereby designate the following individual(s) as my

the right to change the designation I have made below at

beneficiary(ies) (please name up to two beneficiaries if you

any time by sending a new Preretirement Survivor Benefit

are not married – trusts, estates and successor beneficiaries

Designation Form to the NYSNA Pension Plan. I also

are not permitted under this Plan). If Plan records show

understand that if the beneficiaries I have designated are not

that you are married, this form will be rejected and you will

living at the date of my death, no Preretirement Survivor

need to complete a new form to change your beneficiary

Benefit will be payable upon my death unless I am married

designation:

1. Beneficiary

2. Beneficiary

(complete only if you wish to designate a 2nd beneficiary)

Name ___________________________________________

Name ____________________________________________

Relationship ______________________________________

Beneficiary’s Date of Birth __________________________

Beneficiary’s Address _______________________________

_________________________________________________

Beneficiary’s Social Security # ________________________

________________________________________________________________________________________

Your Signature

Date

Please return this form to the

NYSNA Pension Plan

PO Box 12430

Albany, NY 12212-2430

August 2013

Preretirement Survivor Benefit Beneficiary Designation Form For Unmarried Participants Page 2

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