Survivor Beneficiary Designation Form - Public Employees' Retirement System Of Nevada

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Survivor Beneficiary Designation Form

Public Employees’ Retirement System of Nevada

693 W. Nye Lane, Carson City, NV 89703 - (775) 687-4200 - Fax (775) 687-5131

7455 W. Washington Ave., Suite 150, Las Vegas, NV 89128 - (702) 486-3900 - Fax (702) 304-0697

5820 S. Eastern Ave., Suite 220, Las Vegas, NV 89119 - (702) 486-3900 - Fax (702) 678-6934

Toll Free: (866) 473-7768

Name Change  Yes

 No

Member Information

If Yes, Former Name: ____________________________

Name: ______________________________________________________SSN: __________________________ Birth Date: _______________M F

Address: _____________________________________________________________City, State, Zip: ________________________________________

Home Phone: ______________________________Work Phone: __________________________________ Employer: __________________________

 Yes

 No

Married or have a registered domestic partner?

A spouse or registered domestic partner is the member’s primary beneficiary and will be considered first to receive

Family Beneficiary Information

any lifetime benefit available in the event of the member’s death prior to retirement. If a monthly benefit is not available, the spouse or registered

domestic partner may be eligible to receive a one-time, lump-sum payment of any existing member contributions in the System. Children under age 18

may be eligible to receive a limited benefit.

Name of Spouse or Registered Domestic Partner: _________________________________SSN: ________________Birth Date: _____________M F

List all unmarried children (biological or legally adopted) under age 18. (Attach separate sheet if necessary.)

Name: _________________________________________________SSN: __________________________Birth Date: _____________________M F

Survivor Beneficiary Designation

All PERS members should list one person as the Survivor Beneficiary in this area of the form (not a spouse or

registered domestic partner, trust or charitable organization) to receive a lifetime benefit that may be payable in the event of an unmarried

member’s death or a member and spouse’s/registered domestic partner’s simultaneous death prior to retirement. Additional Payees may also be

designated to split the payment with the Survivor Beneficiary by percentage. Monthly payments to Additional Payees cease upon the death of the

designated Survivor Beneficiary.

___________

Benefit

Survivor Beneficiary: (If you do not wish to provide a lifetime benefit for a Survivor Beneficiary/Additional Payees, indicate NONE.)

Percentage

Name: _______________________________________________SSN:____________________ Birth Date: _________________ M F

Address: ______________________________________________City, State, Zip: ____________________________________________

________%

Additional Payees: (Attach separate sheet, if necessary)

Name: _______________________________________________SSN:____________________ Birth Date: _________________ M F

Address: ______________________________________________City, State, Zip: ____________________________________________ ________%

Name: _______________________________________________SSN:____________________ Birth Date: _________________ M F

Address: ______________________________________________City, State, Zip: ____________________________________________ ________%

Name: _______________________________________________SSN:____________________ Birth Date: _________________ M F

Address: ______________________________________________City, State, Zip: ____________________________________________ ________%

TOTAL PERCENTAGES FOR SURVIVOR BENEFICIARY + ALL ADDITIONAL PAYEES =

Survivor Beneficiary & Additional Payee percentages must be whole numbers and total 100% when added together

Total %

Tertiary Beneficiary Designation

The tertiary beneficiary may be eligible to receive a one-time, lump-sum payment of any refundable employee

contributions in the System if no one else listed above is eligible. If more than one person is listed, the payment will be split equally unless otherwise

stated by the member. Charitable organizations and trusts may be designated here. Attach a separate sheet if necessary.

Name: _____________________________________________________SSN:_______________________Birth Date: __________________ M F

Address: _______________________________________________________City, State, Zip: _____________________________________________

For PERS Use - Date Received

I understand that the information designated on this form supersedes all prior beneficiary

designations that I have submitted on other forms, and that this information only affects records with

the Public Employees’ Retirement System.

Member Signature: __________________________________________Date: _______________________

Rev. 2/11