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Beneficiary Designation FOR OFFICE USE ONLY Defined Benefit Plan for Active and Deferred Members Division of Retirement and Benefits P.O. Box 110203 Juneau, Alaska 99811-0203 ❑ Change ❑ PERS Toll-Free: (800) 821-2251 alaska.gov/drb ❑ Initial Designation Juneau: 465-4460 TDD: (907) 465-2805 Fax: (907) 465-3086 ❑ TRS ❑ JRS ❑ EPORS READ CAREFULLY BEFORE COMPLETING: This form is for active or deferred members of the Public Employees' Retirement System (PERS Tier I, II, III), Teachers' Retirement System (TRS I, II), Judicial Retirement System (JRS), National Guard Retirement System (NGRS), and the Elected Public Officers Retirement System (EPORS). The person(s) that you designate as your beneficiary or beneficiaries on this form will receive the retirement system benefits payable upon your death. To change your beneficiary or beneficiaries address, marital status, or other information, complete and send a new form to the above address. NOT FOR SBS OR OPTIONAL LIFE INSURANCE. Section I. Personal Data Is this a new address? Employee's Name (Last, First, M.I.) ❑ Yes ❑ No Social Security Number Page_____ of _____ (Use only if additional forms are attached) Mailing Address (City, State, ZIP + 4) Work Phone Number Marital Status Date of Birth ❑ Married ❑ Single ❑ Home Phone Number Same-sex Partner Employer Name Employer Number Section II. Beneficiary Designation If you are married or a single parent, see the instructions on the back BEFORE designating your beneficiary or beneficiaries. Place an "X" in the appropriate box to specify whether the beneficiary is primary or contingent. The "primary" beneficiary or beneficiaries will receive benefits if you die. The "contingent" beneficiary or beneficiaries will receive benefits ONLY if the primary is deceased. PRIMARY ❑ Last Name, First, M.I. Percentage Mailing Address (City, State, ZIP + 4) PRIMARY ❑ ❑ Last Name, First, M.I. Mailing Address (City, State, ZIP + 4) PRIMARY CONTINGENT ❑ ❑ Last Name, First, M.I. Mailing Address (City, State, ZIP + 4) PRIMARY ❑ ❑ Last Name, First, M.I. CONTINGENT Mailing Address (City, State, ZIP + 4) PRIMARY CONTINGENT ❑ ❑ Last Name, First, M.I. Mailing Address (City, State, ZIP + 4) Relationship Social Security Number Check whether beneficiary is the primary or contingent CONTINGENT Date of Birth ❑ Check if this is an address change for your beneficiary Percentage Date of Birth Relationship Social Security Number Percentage Date of Birth Relationship Social Security Number Percentage Date of Birth Relationship Social Security Number Percentage Date of Birth Relationship Social Security Number I hereby certify that the information provided on this form is true and correct to the best of my knowledge. I understand that any deliberate misrepresentation for the purpose of obtaining benefits is an offense punishable by law. ____________________________________ Signature of Employee 02-822 (12/11) Active and Deferred Vested COMPLETE IN INK OR USE A TYPEWRITER — OVER _________________ Date g:/publicatins/forms/general/02-822.indd/1 Section III. Consent to Beneficiary Designation INSTRUCTIONS If you are MARRIED, your spouse is automatically your 100% primary beneficiary unless he or she consents to another beneficiary. Your spouse's written consent may be waived if: · you were not married to your spouse during any part of your PERS or TRS employment; · you have been married for less than two years and you have established that you and your spouse are not living together; or · your spouse cannot be located. Your spouse may waive entitlement to benefits by completing and signing the "Spouse's Consent" below before a notary public or other authorized person. If you are a SINGLE PARENT, there are death benefits that may be payable to your dependent child if you die before retirement. These benefits are only payable to your children if they are your designated beneficiaries. Because benefits cannot be paid directly to minor children, they will be paid to the children's parent or legal guardian, unless you establish a trust and designate the trust as beneficiary for your children. You should NOT designate another person as beneficiary to receive your children's benefits. Benefits payable to TRS survivors under the 1% Supplemental Contributions provision will be paid in accordance with Alaska Statutes 14.25.162-164. SPOUSE'S CONSENT I, __________________________________________, am the spouse of ________________________________________. I understand that I am entitled to the death benefits that will be paid if my spouse dies. I have reviewed the occupational and nonoccupational death provisions described in the PERS and TRS Information Handbooks. I understand that, depending upon the circumstances of my spouse's death, I may be eligible to receive either a lump sum benefit or monthly benefits for the rest of my life and that major medical insurance will be available to me and my eligible dependents while I am receiving monthly benefits. By signing this consent, I agree to waive my right to any benefits that would be paid to me and consent to the naming of the above beneficiary. Your signature must be witnessed below Signature Date Signature witnessed by: ______________________________________________ or Plan Representative (Must be a designated employee of the Division of Retirement and Benefits) ________________________________________ Notary Public or Postmaster State of _________________________________ My Commission Expires: ___________________ Section IV. Same-Sex Partner Beneficiary Designation Instructions If you wish to designate a same-sex partner to receive survivor benefits that may become available upon your death under 14.25.157, 14.25.160, 14.25.162, 14.25.164, 14.25.167, AS 22.25.030, AS 39.35.420, AS 39.35.430, 39.35.440, 39.35.450, or former AS 39.37.060, you must submit the Same-sex Partner Affidavit, and you must provide the documentation, required by 2 AAC 38.010. Your same-sex partner must be the only “primary” beneficiary listed on this form in order to qualify for the survivor benefits provide by the statutes mentioned above. Reset Form 02-822 (Back) (12/11) Active and Deferred Vested g:/publications/forms/general/02-822.indd/2