Fillable Beneficiary Selection Form (Page 3 of 3) in pdf

Beneficiary Selection Form Page 3

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Beneficiary Selection Form

Member’s Last Name

First

M.I.

Social Security #

To Be Completed by Witness of Choice of Beneficiary of

Accumulated Total Deductions.

Signature of Witness ________________________________________ _ _ Date ____________

Name of Witness (Print) _____________________________________ _

Choice of Option (D) Beneficiary

I, (Print Name)

, a member of the

Retirement System, hereby nominate the beneficiary * listed below, under the provisions of G.L. c. 32, § 12(2)(d)

to receive from the retirement system a benefit equal to the Option (C) retirement allowance which would

otherwise have been payable to me in the event that I die before being retired.

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.

I understand that this choice of Option D Beneficiary can be superceded if, at my death, I leave a spouse to

whom I have been married for over one year and with whom I am living on the date of my death, or if living

apart, for justifiable cause as determined by the Retirement Board.

Beneficiary

Name of Eligible Beneficiary

Beneficiary’s Relationship to Member

Beneficiary’s Date of Birth (Attach birth record)

Beneficiary’s Social Security #

Member

Member’s Signature ________________________________________ _ _ Date ___________

Member’s Street Address

Member’s Social Security #

City/Town

State

Zip

To Be Completed by Witness of Choice of Option D Beneficiary

Witness’ Signature __________________________________________ Date ___________

Witness’ Name (Print)

* An eligible beneficiary is defined under G.L. c. 32, § 12(2)(d) as the spouse, former spouse who has not

remarried, child, father, mother, sister or brother of the member.

CLEAR

Beneficiary Selection Form Page 3

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