Form Trs 100 - Teachers' Retirement System Enrollment Member Information Record Page 2
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2TRS Enrollment Member Information Record
Name ________________________________________________ SSN
Designation
of Primary
I, the undersigned, do hereby designate the following individuals as my primary beneficiary(ies) to whom I instruct the Board
of Control of the Teachers’ Retirement System of Alabama to pay, in the event of my death before retirement on pension, any
Beneficiary(ies)
preretirement death benefit and/or group term life insurance payments due upon my death.
Please give complete
information
Name _____________________________________________ Relationship ________________ Date of Birth __________________
Address _________________________________________________________________________________________
Street or P.O. Box
City
State
ZIP Code
Name _____________________________________________ Relationship ________________ Date of Birth __________________
Address _________________________________________________________________________________________
Street or P.O. Box
City
State
ZIP Code
Designation
In the event the primary beneficiary(ies) designated above does not survive me, I hereby authorize the Teachers’ Retirement System
of Contingent
of Alabama to pay the benefits to the beneficiary(ies) named below.
Beneficiary(ies)
Name _____________________________________________ Relationship ________________ Date of Birth __________________
Please give complete
information
Address _________________________________________________________________________________________
Street or P.O. Box
City
State
ZIP Code
Name _____________________________________________ Relationship ________________ Date of Birth __________________
Address _________________________________________________________________________________________
Street or P.O. Box
City
State
ZIP Code
Signature
I agree on behalf of myself, my heirs, and assigns that payment so made shall be a complete discharge of the claim and shall constitute
Certification
a release of the System from any further obligation on account of the benefit. I hereby direct that should I survive either or both of the
before mentioned beneficiaries, the amount which otherwise would have been payable to the beneficiary had he/she been living shall
be paid to my estate or to such other beneficiary as I shall hereafter nominate by written designation filed with the Teachers’ Retirement
System of Alabama in accordance with the rules and regulations prescribed by the Board of Control. Divorce or annulment of a marriage
shall not revoke or void the designation of a spouse as beneficiary for any benefits payable by RSA.
Sign Here
è
Your Signature ______________________________________________________ Date ___________________
Please have your signature acknowledged before a Notary Public.
____________________
_______________________ , C
S
tate of
ounty of
_____
______________________
________
On this
day of
, 20
, personally appeared before me, the above named
individual and made oath that the statements made are true.
____________________________________
Signature of Notary Public
________________________________________
Seal
My Commission Expires
page 2 of 2
TRS_100
REV 2-17
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