Form F501 - Designation Of Beneficiary(Ies) Post-Retirement Lump-Sum Death Benefit
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1
2F501
NYCERS USE ONLY
*501*
Mail completed form to:
30-30 47th Avenue, 10th Fl
Long Island City, NY 11101
Designation of Beneficiary(ies)
Post-Retirement Lump-Sum Death Benefit
This application is for those who wish to nominate a beneficiary(ies) to receive a post-retirement lump-sum death benefit. If the designated Primary
Beneficiary(ies) predeceases you, the lump-sum payment will be paid to your designated Contingent Beneficiary(ies). If none exists, the lump-sum
benefit will be paid to your estate. NOTE: If the address you provide on this form is different from your address in our system, the new address
will become your official address in our records. If you have any questions, contact our Call Center at 347-643-3000.
Member Number
OR
Pension Number
Last 4 Digits of SSN
Phone Number
(
)
First Name
M.I.
Last Name
in Care of (if applicable)
Address
Apt. Number
City
State
Zip Code
I understand that at the time of my death after retirement, the lump-sum death benefit will be paid to my surviving designated Primary
Beneficiary(ies). If the designated Primary Beneficiary(ies) predeceases me, the lump-sum death benefit will be paid to my designated Contingent
Beneficiary(ies). If none exists, the lump-sum death benefit will be paid to my estate.
I, the undersigned, nominate as my beneficiary(ies) for the lump-sum death benefit payable on my death after retirement:
First Name
M.I.
Last Name
Full Social Security Number
Date of Birth
Relationship
[MM/DD/YYYY]
/
/
Address
Apt. Number
City
State
Zip Code
If this beneficiary is a minor, check here and complete the
%
Percentage
guardian information on Form 137
First Name
M.I.
Last Name
Full Social Security Number
Date of Birth
Relationship
[MM/DD/YYYY]
/
/
Address
Apt. Number
City
State
Zip Code
If this beneficiary is a minor, check here and complete the
%
Percentage
guardian information on Form 137
R12/16
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