Form Ers 100 - Ers Enrollment Member Information Record Page 2
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1
2ERS Enrollment Member Information Record
Employees’ Retirement System of Alabama
PO Box 302150, Montgomery, Alabama 36130-2150
877.517.0020 • 334.517.7000 •
Name ________________________________________________ SSN
Designation
I, the undersigned, do hereby designate the following individuals as my primary beneficiary(ies) to whom I instruct the Board of
of Primary
Control of the Employees’ Retirement System of Alabama to pay, in the event of my death before retirement on pension, the total
Beneficiary(ies)
amount of the accumulated contributions standing to my credit in the retirement system.
Please give complete
Name _____________________________________________ Relationship ________________ Date of Birth __________________
information
Address _________________________________________________________________________________________
Street or P.O. Box
City
State
ZIP Code
Name _____________________________________________ Relationship ________________ Date of Birth __________________
Address _________________________________________________________________________________________
Street or P.O. Box
City
State
ZIP Code
Designation
In the event the primary beneficiary(ies) designated above does not survive me, I hereby authorize the Employees’ Retirement
of Contingent
System of Alabama to pay the benefits to the beneficiary(ies) named below.
Beneficiary(ies)
Name _____________________________________________ Relationship ________________ Date of Birth __________________
Please give complete
information
Address _________________________________________________________________________________________
Street or P.O. Box
City
State
ZIP Code
Name _____________________________________________ Relationship ________________ Date of Birth __________________
Address _________________________________________________________________________________________
Street or P.O. Box
City
State
ZIP Code
Signature
I agree on behalf of myself, my heirs, and assigns that payment so made shall be a complete discharge of the claim and shall constitute
Certification
a release of the System from any further obligation on account of the benefit. I hereby direct that should I survive either or both of
the before mentioned beneficiaries, the amount which otherwise would have been payable to the beneficiary had he/she been living
shall be paid to my estate or to such other beneficiary as I shall hereafter nominate by written designation filed with the Employees’
Retirement System of Alabama in accordance with the rules and regulations prescribed by the Board of Control.
Sign Here
è
Your Signature ______________________________________________________ Date ___________________
Please have your signature acknowledged before a Notary Public.
____________________
_______________________ , C
S
tate of
ounty of
_____
______________________
________
On this
day of
, 20
, personally appeared before me, the above named
individual and made oath that the statements made are true.
____________________________________
Signature of Notary Public
________________________________________
Seal
My Commission Expires
ERS 100
REV 4-16
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