Death Benefit Claimant Form - Richmond Retirement System
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1Death Benefit Claimant Form
DIRECTIONS
PART A. CLAIMANT INFORMATION
Please fill out your form, typed
Name
A1.
or printed in ink, and submit to:
Date of Birth
A2.
730 E. Broad Street, Suite 900
Richmond, VA 23219
Address Line 1
A3.
All forms are processed on the
Address Line 2
A4.
15th of the month, and checks
Phone Number
are mailed the last business day
A5.
of the month.
Email Address
A6.
RRS USE ONLY
You are claiming this benefit: __ as a named beneficiary __ on behalf of an institution or estate.
A7.
___22-296
.
If on behalf of institution or estate (i) attach legal documentation outlining your authority and (ii) provide EIN in Box A8
1.City Code Sec:
___22-297
Social Security #
A8.
#____________
2.Legacy #
Your relationship to the deceased: __ spouse __ child __ friend __other:___________________
A9.
#____________
3.Oracle #
PART B. DECEASED MEMBER INFORMATION
___ / ___ / ___
4.Date of Birth
Name
5.Death Benefit,
$____________
B1.
Less Overpayments
Social Security #
B2.
#____ of ____
6. Beneficiary #
Date of Death
B3.
$____________
7.Payment Amount
Confirm that an original
or original
is attached:
__
CERTIFICATE OF DEATH
VERIFICATION OF DEATH
B4.
___ / ___ / ___
8.Payment Date
PART C. CERTIFICATION
9.Reviewer #1
You must review, sign, and date this form in front of a registered notary.
10.Reviewer #2
By signing the below I certify that the information provided on this form is true, complete, and accurate to the best of my
knowledge. I also certify that I am legally entitled to this benefit.
11.Notes:
Claimant Signature
Date
(must match Box C4)
C1.
C2.
The individual whose name is signed above appeared before me, acknowledged the signature to be his/hers, and having
been sworn by me, made an oath that the statements are true.
Notary Signature
Date
(must match Box C2)
C3.
C4.
Seal / Stamp:
C5.
Notary Printed Name
C6.
City, State
C7.
Commission Expires
C8.
Notary Registration #
C9.
Form revised January 2016
Richmond Retirement System | 730 E. Broad Street, Suite 900, Richmond, Virginia, 23219 | Tel: (804) 646 - 5958 | Fax: (804) 646-5299 |
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