Fillable Form 1856 - Change Of Beneficiary printable pdf download

PUBLIC EMPLOYEES’ RETIREMENT FUND

CHANGE OF BENEFICIARY

P. O. Box 7121

State Form 1856 (R7 / 7-10)

Indianapolis, IN 46207-7121

Telephone: (888) 526-1687 (toll-free)

Web site:

PRIVACY NOTICE

Your Social Security number is being requested by this

agency pursuant to the requirements of IRS Code

Reset

3405. This disclosure is mandatory and this form

cannot be processed without this information

MEMBER INFORMATION

Member’s name

Social Security number

PID number

Address

Telephone number with area code

City

State

ZIP Code

GENERAL INFORMATION

If you do not want a lump sum payment of your death benefit to be paid to your estate, you must designate your beneficiaries.

Be sure to designate each beneficiary as primary or contingent. This list supersedes any list of beneficiaries currently on file

with the Public Employees’ Retirement Fund (PERF) for this member.

A Primary beneficiary will receive all benefits due upon the member’s death. Multiple surviving Primary beneficiaries will

receive shares of the benefits due upon the member’s death based on the percentages indicated on this form. If no

percentages have been supplied for the primary beneficiaries, the beneficiaries will receive equal shares of the benefits.

A Contingent beneficiary will receive all benefits upon the member’s death only if all designated Primary beneficiaries

predecease the member. Multiple Contingent beneficiaries will receive shares provided all designated Primary beneficiaries

predecease the member based on the percentages indicated on this form. If no percentages have been supplied for the

contingent beneficiaries and there are no surviving primary beneficiaries, the contingent beneficiaries will receive equal shares

of the benefits.

The option to choose a beneficiary must be signed by a witness. The witness may be any person other than a beneficiary

named on this form.

A beneficiary change on your PERF Annuity Savings Account (ASA) or an established PERF Rollover Savings Account (RSA)

may be completed online using PERF Online available to members on the PERF Web site located at , or by

contacting a Customer Service Representative, toll-free, at (888) 526-1687.

ANNUITY SAVINGS ACCOUNT (ASA) BENEFICIARY CHANGE

Complete this section if you are making beneficiary designations for your ASA account with PERF. This designation applies to

your Annuity Savings Account (ASA) only. No changes to any other account will be made using this form.

ASA PRIMARY BENEFICIARY DESIGNATION

The Primary beneficiary designations listed in this section replace all ASA beneficiary information submitted previously. The

percentage of benefit to be paid to each Primary beneficiary must be in increments of 1 percent or greater. The total of all

Primary beneficiary percentages must equal 100 percent. If there are more than five ASA beneficiaries, please attach an

additional page with the information.

Date of birth

Social Security

Percent of

Primary beneficiary’s name

Relationship to member

(mm/dd/yyyy)

number/Tax ID

Benefit

ASA CONTINGENT BENEFICIARY DESIGNATION

The Contingent beneficiary designations listed in this section replace all ASA beneficiary information submitted previously.

The percentage of benefit to be paid to each Contingent beneficiary must be in increments of 1 percent or greater. The total of

all Contingent beneficiary percentages must equal 100 percent. If there are more than five ASA beneficiaries, please attach an

additional page with the information.

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Form 1856 - Change Of Beneficiary

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