Beneficiary Selection Form

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Introduction
Beneficiary Selection Form
(If Member Dies Before Retirement)
Form Last Revised: October, 2001
The Beneficiary Selection Form allows a member to select an eligible beneficiary to receive an
allowance if the member dies before retirement and to select a beneficiary(ies) to receive pay-
ment of accumulated deductions and other payments due to a member if the member dies
before retirement. Keep in mind:
Only certain of your relatives qualify as an eligible beneficiary for benefits under G.L. c.
l
32, § 12(2)(d), but any person or entity can be selected as a beneficiary(ies) for a return
of your accumulated total deductions.
Your selection on this form may be superseded by an eligible spouse under the provisions
l
of G.L. c. 32, § 12(2)(d) if you die before retirement.
This form becomes void upon your retirement.
l
If you divorce or your personal situation changes, you may wish to file a new form with
l
your retirement board.
COMMONWEALTH OF MASSACHUSETTS | PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
WEB |

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