One-Time Death Benefit (Page 6 of 6) in pdf

Recipient Designation Form

continued

Justification for Non-Signature of Spouse or Registered Domestic Partner

As required by Education Code sections 22453 and 26703, any request related to the selection of benefits by a member

in which spousal or registered domestic partner interest may be present requires the signature of the spouse or registered

domestic partner unless one of the following conditions exist. If you are married or registered as a domestic partner and your

spouse or partner does not sign this form, you must check the appropriate box indicating the reason your spouse or partner

did not sign.

I do not know and have taken all reasonable steps to determine the whereabouts of my spouse or registered

domestic partner.

My spouse or registered domestic partner is incapable of executing the acknowledgment because of an

incapacitating mental or physical condition.

My current spouse or registered domestic partner has no identifiable community property interest in the benefits.

My spouse or registered domestic partner and I have executed a settlement agreement that makes the

community property law inapplicable to the marriage or registered domestic partnership.

My spouse or registered domestic partner has refused to sign the acknowledgment. Court action will be or has been initiated

to enforce or waive the signature requirement for my spouse or partner. (CalSTRS must have a certified copy of the court

order before any designation can be made. Submit a certified copy of the court order when you receive it.) Education Code

sections 22454 and 26704

I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

I understand that perjury is punishable by imprisonment for up to four years (Penal Code section 126).

I understand it is a crime to fail to disclose a material fact or to make any knowingly false material statements for

the purpose of altering a benefit administered by CalSTRS and it may result in penalties, including restitution, up to

one year in jail and a fine of up to $5,000 (Education Code section 22010).

MEMBER’S SIGNATURE

SIGNATURE DATE (MM/DD/YYYY)

If this form is not completely filled out, it will not be accepted and will be returned to you. Your current

recipient status will not be updated. Review your form carefully before submitting:

Did you designate at least one primary recipient and provide all the requested information?

If you designated a trust, did you provide the name and date the trust was created? Do not provide your trust

document at this time.

If you designated percentages, do they equal 100 percent for your primary recipients and 100 percent for your

secondary recipients?

Did you sign and date the form?

If you are married or in a registered domestic partnership, did your spouse or partner sign and date the form?

If you cannot obtain your spouse or partner’s signature, did you complete, sign and date the Justification for

Non-Signature of Spouse or Registered Domestic Partner?

RECIPIENT DESIGNATION FORM • REV 01/15 • PAGE 4 OF 4

One-Time Death Benefit Page 6