Application For A Disability Allowance Page 4
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12CT TEACHERS’ RETIREMENT BOARD
765 ASYLUM AVENUE HARTFORD, CT 06105-2822
Toll-Free 1-800-504-1102
(860) 241-8400
Fax (860) 241-9295
BENEFICIARY ELECTION FOR DISABILITY ALLOWANCE FORM
Section 10-183(h) of the Connecticut General Statutes requires that monthly survivor benefits be paid to the statutory
survivors of members who die while active before any balance is paid to your designated beneficiary. This is true regardless
of whom you designated as your beneficiary. A statutory survivor includes but is not limited to a spouse and/or a minor child
under the age of 18. Refer to our
Survivorship Benefits Before Retirement Bulletin
before completing this form. This
form supersedes and replaces any previous beneficiary designations.
All items pertaining to beneficiaries must be
completed in order for the Connecticut Teachers’ Retirement Board (CTRB) to process the form; incomplete forms will be
returned.
▪
Include a complete list of all beneficiaries.
▪
Type or print clearly in ink and do not use white out.
▪
Do not submit an amended copy of a previous beneficiary form.
▪
You may name any living person, your estate, a trust, or a charitable organization as your beneficiary.
▪
At least one primary beneficiary must be named. If more than one primary beneficiary is named, the share of any
beneficiary who dies before you shall be divided equally among the surviving primary beneficiaries.
▪
A payment is made to a contingent beneficiary(ies) only if all primary beneficiaries die before you do.
▪
If you survive all of the beneficiaries named, payment would be issued to your estate.
▪
“Per Stirpes” designations (unnamed or unborn beneficiaries) are not accepted.
▪
All information must appear in the appropriate section of this form.
▪
To designate a trust as a beneficiary enter the name and date of the trust agreement in the Beneficiary section of this
form; leave the Relationship and Social Security sections of this form blank; and indicate Primary or Contingent.
▪
To designate your estate as a beneficiary enter the word “Estate” in the Beneficiary section of this form; leave the
Relationship and Social Security sections of the form blank; and indicate Primary or Contingent.
MEMBER NAME (First Name, Middle Initial, Last Name)
SOCIAL SECURITY #
STREET ADDRESS
E-MAIL ADDRESS
CHECK IF:
CITY, STATE, ZIP
NEW ADDRESS
NAME CHANGE
BENEFICIARY NAME AND ADDRESS (include ZIP Code)
RELATIONSHIP
SOCIAL SECURITY #
CHECK ONE
Name:
primary
contingent
Address:
Name:
primary
contingent
Address:
Name:
primary
contingent
Address:
Name:
primary
contingent
Address:
Use additional Beneficiary Election for Disability Allowance forms to designate additional beneficiaries.
If you have a spouse who you have not designated as a beneficiary, you need to check this box to waive the
statutory survivorship benefits for your spouse in order for your designated beneficiary to receive the funds in your
account in the event of your death prior to your conversion to a normal retirement benefit.
SIGNATURE OF MEMBER
DATE
CTRB does not acknowledge the receipt of individual forms. Please retain a copy of this form for your records and forward it by
fax or regular mail directly to CTRB at the address above.
DisBenChg (050916)
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