Form Rsa 100-C - Change Of Beneficiary Form Prior To Retirement

ADVERTISEMENT

C
B
F
RSA 100-C
HANGE OF
ENEFICIARY
ORM
Check One:
01/09
P
 ERS
RIOR TO RETIREMENT
Page 1 of 2
 TRS
Retirement Systems of Alabama
P. O. Box 302150  Montgomery, AL 36130-2150
334-517-7000 or 877-517-0020
Instructions: Please print or type in black ink. Complete the Member Information, Beneficiary Change/Correction, and
Member Authorization sections of this form. This form must be signed and notarized for changes to be activated.
Do NOT use this form if you are retired or participating in DROP. Please contact the RSA for
the proper form.
M
I
(Must be completed in all cases)
EMBER
NFORMATION
Name: __________________________________________________
Social Security No.:
-
-
First
Middle/Maiden
Last
Date of Birth:
/
/
Home Phone No.: (
)
Membership Status:  Active Member
 Inactive Member
B
C
/C
ENEFICIARY
HANGE
ORRECTION
To name multiple beneficiaries, use the back of this form.
D
P
B
E S I G N A T I O N O F
R I M A R Y
E N E F I C I A R Y
Name:
Relationship:
Date of Birth:
/
/
-
-
Address:
Social Security Number
Street or P. O. Box
City
State
Zip Code
D
C
B
E S I G N A T I O N O F
O N T I N G E N T
E N E F I C I A R Y
Contingent Beneficiaries will receive benefits only if all Primary Beneficiaries are deceased.
Name:
Relationship:
Date of Birth:
/
/
-
-
Address:
Social Security Number
Street or P. O. Box
City
State
Zip Code
(  )
Check
if Beneficiary information is continued on the back of this form.
(
)
M
A
(Must be signed and notarized)
EMBER
UTHORIZATION
Signature of Member:
Date of Signature:
/
/
N
OTARY
S
, C
TATE OF
OUNTY OF
On this
day of
, 20
, personally appeared before me, the above named individual and made oath that the
statements made are true.
Signature of Notary Public
My Commission Expires

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2