Beneficiary Selection Form Page 2
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1
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3Beneficiary Selection Form
(If Member Dies Before Retirement)
Form Last Revised: October, 2001
Retirement
Board: Please
place your address
and phone
number here. 4
Choice of Beneficiary to Receive a Return of Accumulated Total Deductions
at Member’s Death
I, (Print Name)
, a member of the
Retirement System hereby request the Board of Retirement to pay any sum referred to in G.L. c. 32, § 11(2)*
due at my death to the following beneficiary or beneficiaries in the proportions designated.
My selection may be superseded by a selection under G.L. c. 32, § 12(2)(d) if I die leaving an eligible spouse
who elects to receive a monthly benefit.
I understand that I may change my beneficiary designation at any time prior to my retirement and that upon
my retirement, this form becomes void.
*The types of payments covered under G.L. c. 32, § 11(2) include:
The payment of the accumulated deductions credited to a member's account in the annuity savings fund at
l
the date of death when the member's death occurs prior to his/her retirement.
The amount of any uncashed checks payable to a member at his or her death.
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Any person or entity may be a beneficiary under G.L. c. 32, § 11(2). Give complete name and address of
l
each beneficiary below:
Proportion To Be Paid
Name
SSN
Address
Name
SSN
Address
Name
SSN
Address
Name
SSN
Address
Member’s Signature __________________________________________ Date ____________
Member’s Address
COMMONWEALTH OF MASSACHUSETTS | PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
WEB |
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