Form 02-822 - Beneficiary Designation Defined Benefit Plan For Active And Deferred Members - 2009

Download a blank fillable Form 02-822 - Beneficiary Designation Defined Benefit Plan For Active And Deferred Members - 2009 in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 02-822 - Beneficiary Designation Defined Benefit Plan For Active And Deferred Members - 2009 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Beneficiary Designation

FOR OFFICE USE ONLY

Defined Benefit Plan

for Active and Deferred Members

Division of Retirement and Benefits

Juneau: 465-4460

Toll-Free: 1-800-821-2251

PO Box 110203

TDD: (907) 465-2805

Fax: (907) 465-3086

Juneau, Alaska 99811-0203

❑

Change

❑

PERS

❑

TRS

❑

JRS

❑

EPORS

Initial Designation

READ CAREFULLY BEFORE COMPLETING: This form is for active or deferred members of the Public Employees' Retirement System (PERS Tier I, II, III), Teachers' Retirement System

(TRS I, II), Judicial Retirement System (JRS), National Guard Retirement System (NGRS), and the Elected Public Officers Retirement System (EPORS). The person(s) that you designate

as your beneficiary or beneficiaries on this form will receive the retirement system benefits payable upon your death. To change your beneficiary or beneficiaries address, marital status, or

other information, complete and send a new form to the above address. NOT FOR SBS OR OPTIONAL LIFE INSURANCE.

❑

Section I. Personal Data

Is this a new address?

Yes

Employee's Name (Last, First, M.I.)

Social Security Number

Page_____ of _____

(Use only if additional forms are attached)

Mailing Address (City, State, ZIP + 4)

Work Phone Number

(

)

Marital Status

Date of Birth

Home Phone Number

❑

Married

Single

Same-sex Partner

(

)

Employer Name

Employer Number

Section II. Beneficiary Designation

If you are married or a single parent, see the instructions on the back BEFORE designating your beneficiary or beneficiaries.

Place an "X" in the appropriate box to specify whether the beneficiary is primary or contingent. The "primary" beneficiary or beneficiaries

will receive benefits if you die. The "contingent" beneficiary or beneficiaries will receive benefits ONLY if the primary is deceased.

❑

PRIMARY

Last Name, First, M.I.

Percentage

Date of Birth

Relationship

Mailing Address (City, State, ZIP + 4)

Social Security Number

❑

Check whether beneficiary is the primary or contingent

Check if this is an address change for your beneficiary

❑

PRIMARY

Last Name, First, M.I.

Percentage

Date of Birth

Relationship

❑

CONTINGENT

Mailing Address (City, State, ZIP + 4)

Social Security Number

❑

Last Name, First, M.I.

Percentage

Date of Birth

Relationship

PRIMARY

❑

CONTINGENT

Mailing Address (City, State, ZIP + 4)

Social Security Number

❑

Last Name, First, M.I.

Percentage

Date of Birth

Relationship

PRIMARY

❑

CONTINGENT

Mailing Address (City, State, ZIP + 4)

Social Security Number

❑

Last Name, First, M.I.

Percentage

Date of Birth

Relationship

PRIMARY

❑

CONTINGENT

Mailing Address (City, State, ZIP + 4)

Social Security Number

I hereby certify that the information provided on this form is true and correct to the best of my knowledge. I understand that any deliberate misrepresentation

for the purpose of obtaining benefits is an offense punishable by law.

____________________________________

___________________

____________________________________

_________________

Signature of Employee

Date

Signature of Witness

Date

(must not be a beneficiary)

02-822 (5/09)

g:/publicatins/forms/general/02-822.indd/1