Form 1856 - Application For Change Of Beneficiary - Public Employees' Retirement Fund Page 2
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1
2Member Name (Last, First, Middle Initial)
Social Security Number
_ _ _ - _ _ - _ _ _ _
BENEFICIARY INFORMATION (
Attach Additional Copies of this Page if Necessary)
Primary Beneficiary or Beneficiaries
Beneficiary Name (Last, First, Middle Initial)
Social Security Number or Tax ID
Date of Birth (mm/dd/yyyy)
Relationship to Member
Street Address
City
State
Zip Code
Beneficiary Name (Last, First, Middle Initial)
Social Security Number or Tax ID
Date of Birth (mm/dd/yyyy)
Relationship to Member
Street Address
City
State
Zip Code
Contingent Beneficiary or Beneficiaries
Beneficiary Name (Last, First, Middle Initial)
Social Security Number or Tax ID
Date of Birth (mm/dd/yyyy)
Relationship to Member
Street Address
City
State
Zip Code
Beneficiary Name (Last, First, Middle Initial)
Social Security Number or Tax ID
Date of Birth (mm/dd/yyyy)
Relationship to Member
Street Address
City
State
Zip Code
In accordance with the provisions of Indiana Code § 5-10.2-3, I designate my beneficiary or beneficiaries as shown above. If the
primary beneficiary or beneficiaries herein designated survive me, they shall receive the funds, if any, that are payable by the fund to
a designated beneficiary. If the primary beneficiary or beneficiaries do not survive me, then the contingent beneficiary or beneficiaries
shall receive such funds. If none survive me, then the beneficiary shall be my estate. If no designation is made, any death benefit
due would be payable to my estate. I reserve the right to change the primary or contingent beneficiaries at any time prior to
distribution of my Annuity Savings Account by filing a Change of Beneficiary form with the Board of Trustees of the Fund. Such a
change must be received and accepted by the fund for it to become effective.
I understand that this designation of beneficiary supersedes and replaces any prior designation of beneficiary or beneficiaries that
may have been made in the course of this or any prior employment in a PERF-covered position with any other employer.
Signature of Member
Printed Name
Date
Signature of Witness
Printed Name
Date
APPLICATION FOR CHANGE OF BENEFICIARY
(Annuity Savings Account or Rollover Account)
Page 2 of 2
State Form 1856 (R4/06-05)
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