Form 1856 - Application For Change Of Beneficiary - Public Employees' Retirement Fund
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1
2PRIVACY NOTICE
APPLICATION FOR CHANGE OF
All Social Security Numbers are requested by this
BENEFICIARY
agency in accordance with the requirements of the
Internal Revenue Code. Disclosure is mandatory
(Annuity Savings Account or Rollover
and this form will not be processed without this
Account)
information.
State Form 1856 (R4/06-2005)
INSTRUCTIONS:
1. Please TYPE or PRINT. Use black ink.
2. Complete all information. Remember to put your name and Social Security Number at the top of every page.
3. You must sign at the bottom of page 2 and any additional pages. Each page must be witnessed by
someone who is not your beneficiary.
4. Draw a line through any unused beneficiary information boxes.
5. Return the completed form directly to PERF.
You have the right to change your primary and/or contingent beneficiary or beneficiaries at any time prior to distribution of your Annuity
Savings Account or Rollover Account. Your beneficiary or beneficiaries can only be changed by filing this form with PERF at the
following address:
Public Employees' Retirement Fund
143 West Market Street
Indianapolis, IN 46204
This Change of Beneficiary revokes and replaces all previously named beneficiaries. You must list everyone that you wish to name as a
beneficiary.
In lieu of an individual, you may name a trust or legal entity as a beneficiary. You must furnish PERF with the name, address, and Social
Security Number or Tax Identification Number of each beneficiary. If you wish to name additional beneficiaries, you may attach copies
of page 2 containing the necessary information. Be certain to initial the box below and indicate the number of additional pages. Each
page must be signed and witnessed by someone who is not your beneficiary.
This is for my:
Annuity Savings Account
Rollover Account
Applicant Information
Social Security Number
_ _ _ - _ _ - _ _ _ _
First Name
Middle Initial Last Name
Mailing Address
City
State
Zip Code
Daytime Phone Number
Evening Phone Number
E-mail Address
Important:
Number of Additional Pages
If you have attached additional pages of beneficiaries, you
Initial Here
must initial the box and indicate the number of additional
pages you have attached.
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