Form 1856 - Change Of Beneficiary Page 2
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1
2MEMBER INFORMATION
Member’s name
Social Security number
PID number
ASA CONTINGENT BENEFICIARY DESIGNATION (CONTINUED)
Date of birth
Social Security
Percent of
Contingent beneficiary’s name
Relationship to member
(mm/dd/yyyy)
number/Tax ID
Benefit
1.
%
2.
%
3.
%
4.
%
5.
%
ROLLOVER SAVINGS ACCOUNT (RSA) BENEFICIARY CHANGE
Complete this section if you are making beneficiary designations for your RSA account with PERF. This designation
applies to your RSA only. No changes to any other account will be made using this form.
RSA PRIMARY BENEFICIARY DESIGNATION
The Primary beneficiary designations listed in this section replace all RSA 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 RSA 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
1.
%
2.
%
3.
%
4.
%
5.
%
RSA CONTINGENT BENEFICIARY DESIGNATION
The Contingent beneficiary designations listed in this section replace all RSA 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 RSA
beneficiaries, please attach an additional page with the information.
Date of birth
Social Security
Percent of
Contingent beneficiary’s name
Relationship to member
(mm/dd/yyyy)
number/Tax ID
Benefit
1.
%
2.
%
3.
%
4.
%
5.
%
MEMBER AFFIDAVIT
The member attests that all changes and information provided on this document are true to the best of his/her
knowledge.
Member’s signature
Date
(mm/dd/yyyy)
Witness’ signature
Date
(mm/dd/yyyy)
615 01 034
SOI-F24
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