Form 2rc - Designating Beneficiary(Ies) For Retirement System Return Of Contributions

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Designating Beneficiary(ies) for Retirement
System Return of Contributions
Please print or type in black ink.
No erasures, strikeovers, or white-outs permitted in Sections C through H.
Section A.
Tell us about yourself.
SUFFIX
FIRST NAME
MI
LAST NAME
SSN (Last 4 digits)
MEMBER ID
MAILING ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE NO.
DATE OF BIRTH
E-MAIL ADDRESS
You may not use this form to change your address. See your employer or visit to change your address.
Section B.
Please check the Retirement System that applies and list your current employer.
A separate form is required for each System. Please note that this form, 2RC, is for active members only. Retirees of any System
should use a Form 336 to designate beneficiary(ies) for undistributed contributions. Consolidated Judicial Retirement System
(CJRS) active members should not complete this Form 2RC. CJRS members should only complete Form 2DB.
Teachers' and State Employees' Retirement System (TSERS)
Legislative Retirement System (LRS)
Local Governmental Employees' Retirement System (LGERS)
CURRENT EMPLOYER
Section C.
Complete the following pages and then authorize them with your signature here.
I hereby authorize the Board of Trustees to make payment(s) to the beneficiary(ies) I have designated on page 2 of this form. I
acknowledge that the payments shall be a complete discharge of any claim and shall constitute a release of the Retirement
System from any further obligation on my account. I understand that by completing and signing this form, I acknowledge having
read the Guides. I reserve the right to change the beneficiary(ies) designated on page 2 of this form in accordance with the
information provided. In addition, I understand that the Retirement System will not accept this form with any erasures, strikeovers,
or white-outs in Sections C through H. I certify by my signature that I have completed all pages of this form.
Signature _______________________________________________________________________ Date___________________
Section D.
Please have this form notarized. Improperly notarized forms will not be accepted.
Notary Public Certification
State of
County of
, a notary public for said State and County,
I,
INK SEAL
do hereby certify that
personally appeared
HERE
before me this date and acknowledged the due execution of this Form 2RC.
Witness my hand and official seal this the
day of
, 20
Signature of Notary
My Commission Expires
_________________________________________________________
Section E.
After the completed and signed form is notarized, please submit the form by mail.
You may mail the completed form to the address below. Your beneficiary designation will not be valid until this form has been
properly completed, notarized, and received by our office prior to your death. If any erasures, strikeovers, or white-outs are
found in any signature line, beneficiary designations, or notary section, this form will not be acceptable, and you will need to
complete a new Form 2RC. Upon receipt of this form, the Retirement System will mail an acknowledgment letter to you. Only the
Form 2RC most recently received by the Retirement Systems Division and properly completed and notarized will be effective.
Please continue to the next page.
N.C. Department of State Treasurer, Retirement Systems Division
REV 20100519
2RC
325 North Salisbury Street, Raleigh, North Carolina 27603-1385
(919) 807-3050 in the Raleigh area or (877) 627-3287 toll free
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