Form Tmrs -Bene - Beneficiary Designation Before Retirement

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Beneficiary Designation Before Retirement

MEMBER INFORMATION

Please type or use only black or blue ink and do not highlight. Any corrections must be initialed.

Member’s Name (first, middle, last)

TMRS ID Number (not required)

Social Security Number

Mailing Address

City

State Zip

Daytime Phone Number

MARITAL STATUS

(must check one):

Not married (If married, see Spousal Consent section

below.)

Married

PRIMARY BENEFICIARY DESIGNATION (Limit 3)

Please read instructions carefully. If desired, alternate beneficiary designations may be

completed on page 2. For more information about designating custodians for minors (under 21), please see the attached instructions.

⊲

Beneficiary’s Full Name (first, middle, last)

Social Security Number

Male

Female • Relationship:

Spouse

Non-Spouse

Date of Birth (MM/DD/YYYY)

Custodian’s Name if beneficiary age under 21 (optional)

Custodian’s Relationship to Beneficiary

⊲

Beneficiary’s Full Name (first, middle, last)

Social Security Number

Male

Female • Relationship:

Spouse

Non-Spouse

Date of Birth (MM/DD/YYYY)

Custodian’s Name if beneficiary age under 21 (optional)

Custodian’s Relationship to Beneficiary

⊲

Beneficiary’s Full Name (first, middle, last)

Social Security Number

Male

Female • Relationship:

Spouse

Non-Spouse

Date of Birth (MM/DD/YYYY)

Custodian’s Name if beneficiary age under 21 (optional)

Custodian’s Relationship to Beneficiary

MEMBER SIGNATURE REQUIRED

Making false or misleading statements on any form submitted to TMRS is a violation of State law and has criminal and potential civil liability. I hereby revoke all prior beneficiary designa-

tions. I direct TMRS to pay, if I die before retirement, all of my TMRS benefits (including Supplemental Death Benefit (SDB), if any) to the beneficiary(ies) listed on this form. If I am not

currently vested, I understand that when I vest, this designation becomes invalid and I must resubmit a new beneficiary designation form with TMRS (even if I do not

change my beneficiary(ies). If a beneficiary dies, or I divorce a beneficiary, then this designation becomes void for that person. If I name more than one beneficiary, my benefits will

be divided equally among surviving primary beneficiaries, unless otherwise stated. BY SIGNING THIS FORM, I CERTIFY THAT I HAVE READ THE ATTACHED INSTRUCTIONS, MY MARITAL STATUS IS

CORRECT, AND ALL OF THE INFORMATION I HAVE PROVIDED IS CORRECT.

Member’s Signature

Date Signed (MM/DD/YYYY)

SPOUSAL CONSENT (only to be completed for certain cases, see below)

Your spouse must complete this section in front of a notary only if you are vested and married, and if your spouse is not designated as your only primary

beneficiary. See the instructions on the following page for more clarification.

I understand that my consent is required before my spouse can designate anyone other than me as primary beneficiary. I hereby consent to the beneficiary(ies) designated above.

Spouse’s Printed Name

Spouse’s Signature

State of

County of

, 20

This instrument was acknowledged before me on the

day of

Name of Spouse

Notary Public, State of

(SEAL ⊲ )

(Name of State)

*TMRSBENE*