Designation of Beneficiary/Beneficiaries
MCPS Form 455-5
Employee and Retiree Service Center
August 2015
MONTGOMERY COUNTY PUBLIC SCHOOLS
45 West Gude Drive, Suite 1200, Rockville, Maryland 20850
INSTRUCTIONS: Please return completed form to the address listed above. Print clearly. Retain a copy for your records.
Is this request to change beneficiary/beneficiaries?
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Yes
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No
Working
Vested
Retired (if retiring, retirement date
_____/ 01 /______)
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IMPORTANT: (If you are retired under Option C or D, STOP. You cannot change your beneficiary.)
EMPLOYEE ID NUMBER: 0000 ___ ___ ___ ___ ___
SOCIAL SECURITY NUMBER Last 4 digits ___ ___ ___ ___
NAME (PLEASE PRINT)
First_________________________________________ MI ____ Last _____________________________________________________________
HOME ADDRESS
Street ____________________________________________________ City__________________________ State_____ Zip Code___________
Subject to the terms of the Montgomery County Public Schools Employees’ Retirement Pension, and Reformed Pension System (Plan),
I request that any sum becoming payable by reason of my death be payable to the following beneficiary/beneficiaries. (Enter name,
address, social security number, and relationship to you.)
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Check if you used an additional MCPS Form 455-5 to name additional primary beneficiaries.
PRIMARY BENEFICIARY/BENEFICIARIES
Relationship* ______________SS No. __ __ __ - __ __ - __ __ __ __ Gender
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M
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F Date of Birth (MM/DD/YYYY) ____/____/______
Name _________________________________________________ Address_______________________________________________________
*If spouse, please indicate state/jurisdiction where marriage license issued: _______________________ Date of marriage ____/____/______
Relationship _______________SS No. __ __ __ - __ __ - __ __ __ __ Gender
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M
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F Date of Birth (MM/DD/YYYY) ____/____/______
Name _________________________________________________ Address_______________________________________________________
CONTINGENT BENEFICIARY/BENEFICIARIES (if none of the above named Primary Beneficiary/Beneficiaries survive me.)
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Check if you used an additional MCPS Form 455-5 to name additional contingent beneficiaries.
Relationship* ______________SS No. __ __ __ - __ __ - __ __ __ __ Gender
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M
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F Date of Birth (MM/DD/YYYY) ____/____/______
Name _________________________________________________ Address_______________________________________________________
Relationship* ______________SS No. __ __ __ - __ __ - __ __ __ __ Gender
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M
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F Date of Birth (MM/DD/YYYY) ____/____/______
Name _________________________________________________ Address_______________________________________________________
I designate the above named person(s) as the beneficiary or beneficiaries to whom I request Montgomery County Public Schools
(MCPS) to pay in the event of my death in active service, the total amount of the accumulated contributions standing to my credit
in the Plan and, if I have completed at least one year of creditable service upon my death in active service, the death benefit as
indicated in Section 13 of the Plan.
I hereby authorize Aetna Life Insurance Company to make payment to the beneficiary or beneficiaries, whom I have inserted above
and agree on behalf of myself and my heirs and assigns, that payment so made shall be a complete discharge of the claim and shall
constitute a release of MCPS from any further obligation on account of the benefit. I hereby direct that should both the primary
and contingent beneficiary or beneficiaries of the above-named benefit predecease me, the amount which otherwise would have
been payable to such beneficiary or beneficiaries, shall become a part of and be paid to my estate, or to such other beneficiary or
beneficiaries as I shall hereafter nominate, by written designation filed with MCPS, in accordance with the rules and regulations
prescribed by the Plan.
If more than one person is named beneficiary, any benefit payments that they may become entitled to receive from MCPS will,
unless provided herein, be paid in equal shares to such of the designated persons, survivor or survivors, as shall be living at the time
of my death.
Employee Signature
Date