Form 303 - Spousal Waiver - 2016
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1Form
Spousal Waiver
303
(Rev. 2016)
Purpose of the Form
•
Use this form to indicate a spouse or California Registered Domestic Partner is waiving CCCERA survivor benefits.
Instructions
•
Complete the form in blue or black ink.
Employee
Full Name
Social Security #
Employee #
If you are legally married or a California Registered Domestic Partner, and have not designated your spouse or domestic partner
as sole Beneficiary, your spouse must sign where indicated below. Also, a notary must witness his/her signature.
Under California and federal law, a spouse is entitled to revoke a spousal waiver. The waiver is revocable prior to the death of
the participant or the spouse. If the waiver/designation is not revoked prior to the death of the participant or spouse, the waiver
becomes valid and irrevocable.
Spouse
I understand that I have not been named sole Primary Beneficiary and that in signing this document I have waived my right to
receive the total benefits payable from this Plan in the event of my spouse’s death.
Full Name
Spouse Signature
Date – mm/dd/yyyy
Notary – CALIFORNIA ALL PURPOSE ACKNOWLEDGEMENT
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which
this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California
)
County of _________________________ )
On ___________________________________________ before me, __________________________________________________
Date
Here Insert Name and Title of the Officer
personally appeared _______________________________________________________________________________________ ,
Name(s) of Signer(s)
________________________________________________________________________________________________________ ,
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument
and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their
signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws
of the State of California that the foregoing paragraph
is true and correct.
WITNESS my hand and official seal.
Signature ___________________________________
Signature of Notary Public
Place Notary Seal Here
Contra Costa County Employees’ Retirement Association
1355 Willow Way, Suite 221, Concord, CA 94520
925-521-3960 • 925-521-3969 Fax •
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