Form F501 - Designation Of Beneficiary(Ies) Post-Retirement Lump-Sum Death Benefit Page 2
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2F501
NYCERS USE ONLY
Mail completed form to:
30-30 47th Avenue, 10th Fl
Long Island City, NY 11101
Member Number OR
Pension Number
Last 4 Digits of SSN
If the foregoing Primary beneficiary(ies) should predecease me, I hereby nominate the following as Contingent beneficiary(ies) for
the above Post-Retirement Lump-Sum Death Benefit.
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
I am nominating my Estate as my beneficiary for my post-retirement lump-sum death benefit. I understand that in order
for this selection to be valid I may not write in any other beneficiary's name on this form, and I have, in fact, left all other
designation of beneficiary sections on this form blank.
Should I survive all designated beneficiaries, the post-retirement lump-sum death benefit shall be paid to my Estate or to such other
beneficiary or beneficiaries as I shall hereafter nominate by filing another designation of beneficiary form with NYCERS.
Signature of Member
Date
Witnessed by (1):
(Witnesses necessary only if mark is
used for signature)
Witnessed by (2):
This form must be acknowledged before a Notary Public or Commissioner of Deeds
State of
County of
On this
day of
2 0
, personally appeared
before me the above named,
, to me known, and known to
me to be the individual described in and who executed the foregoing instrument, and he or she acknowledged to me that he or she
executed the same, and that the statements contained therein are true.
If you have an official seal, affix it
Signature of Notary Public or
Commissioner of Deeds
Official Title
Expiration Date of Commission
Sign this form and have it notarized, THIS PAGE
R12/16
Page 2 of 2
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