Change of Beneficiary
Active Member
Public Employees' Retirement Fund
State Form 1856 (R2 3/98)
Approved by the State Board of Accounts 1998
Member's Name: First, Middle, (Maiden), Last
Member's Social Security Number
Member's Address:
Street
City
State
ZIP
You have the right to change your primary and/or contingent beneficiary or beneficiaries at any time while in active employment. 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
Suite 800
Indianapolis, IN 46204
In lieu of an individual, you may name a trust or legal entity as a beneficiary. According to the IRS Code, Section 6041(A), this agency is required to
obtain your Social Security Number. This form cannot be processed without it. In addition, 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 pages
containing the necessary information. Each page must be signed and witnessed.
This Change of Beneficiary revokes and replaces all previously named beneficiaries. You must list everyone that you wish to name as a beneficiary.
Primary Beneficiary
Beneficiary's Name: First, Middle, (Maiden), Last
Beneficiary's Name: First, Middle, (Maiden), Last
Beneficiary's Social Security Number or Tax Identification Number
Beneficiary's Address:
Street
City
State
ZIP
Beneficiary's Date of Birth
Beneficiary's relationship to member
Contingent Beneficiary
Beneficiary's Name: First, Middle, (Maiden), Last
Beneficiary's Name: First, Middle, (Maiden), Last
Beneficiary's Social Security Number or Tax Identification Number
Beneficiary's Address:
Street
City
State
ZIP
Beneficiary's Date of Birth
Beneficiary's relationship to member
I revoke all beneficiaries previously designated by me and hereby designate the aforelisted beneficiary or beneficiaries
Member's Signature
Witnessed by
Date
Address
1
