Form PERS09M0301 DMC "Survivor and Beneficiary Information - Judges' Retirement System" - California

What Is Form PERS09M0301 DMC?

This is a legal form that was released by the California Public Employees' Retirement System - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2010;
  • The latest edition provided by the California Public Employees' Retirement System;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form PERS09M0301 DMC by clicking the link below or browse more documents and templates provided by the California Public Employees' Retirement System.

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Download Form PERS09M0301 DMC "Survivor and Beneficiary Information - Judges' Retirement System" - California

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C
Judges’ Retirement System
P.O. Box 942705
Sacramento, CA 94229-2705
TTY: For Speech & Hearing Impaired - (916) 795-3240
(916) 795-3688, FAX (916) 795-1500
Judges’ Retirement System
SURVIVOR AND BENEFICIARY INFORMATION
Name_____________________________________________ Social Security Number ________-______-________
In accordance with the provision for Government Code Sections 75104 and 75104.5 (Judges’ Retirement Law):
Section A – Spouse/Registered Domestic Partner Information
The following is my current spouse/domestic partner’s information who will be eligible to receive benefits(s) if
he/she survives me:
_____________________________________________________________
________-______-________
Spouse/Registered Domestic Partner’s Name
Social Security Number
____________________________________________
__________________________________________
Date of Birth
Date of Marriage/Registered Partnership
(mm/dd/yyyy)
(mm/dd/yyyy)
Section B – Child(ren)
The following is/are the name(s) of my child(ren) who will be eligible to receive benefit(s) upon my death if
there is no surviving spouse.
_________________________________________
__________-________-________
___________________
Child’s Full Name
Social Security Number
Date of Birth
(mm/dd/yyyy)
_________________________________________
__________-________-________
___________________
Child’s Full Name
Social Security Number
Date of Birth
(mm/dd/yyyy)
_________________________________________
__________-________-________
__________________
Child’s Full Name
Social Security Number
Date of Birth
(mm/dd/yyyy)
Section C – Designated Beneficiary
The following is the designation of a beneficiary eligible to receive my benefit(s), if payable.
_________________________________________
__________-________-________
__________________
Full Name
Social Security Number
Date of Birth
(mm/dd/yyyy)
Should I survive the above named beneficiaries, I request and authorize that such death benefits be paid to
my estate or to such other beneficiaries as I may hereafter designate in writing duly filed with the JRS, all in
accordance with the provisions of the JRS Law.
____________________________________________________________________________________________
Member’s Signature
Date
(mm/dd/yyyy)
PERS09M0301 DMC (11/10)
California Public Employees’ Retirement System
www.calpers.ca.gov
C
Judges’ Retirement System
P.O. Box 942705
Sacramento, CA 94229-2705
TTY: For Speech & Hearing Impaired - (916) 795-3240
(916) 795-3688, FAX (916) 795-1500
Judges’ Retirement System
SURVIVOR AND BENEFICIARY INFORMATION
Name_____________________________________________ Social Security Number ________-______-________
In accordance with the provision for Government Code Sections 75104 and 75104.5 (Judges’ Retirement Law):
Section A – Spouse/Registered Domestic Partner Information
The following is my current spouse/domestic partner’s information who will be eligible to receive benefits(s) if
he/she survives me:
_____________________________________________________________
________-______-________
Spouse/Registered Domestic Partner’s Name
Social Security Number
____________________________________________
__________________________________________
Date of Birth
Date of Marriage/Registered Partnership
(mm/dd/yyyy)
(mm/dd/yyyy)
Section B – Child(ren)
The following is/are the name(s) of my child(ren) who will be eligible to receive benefit(s) upon my death if
there is no surviving spouse.
_________________________________________
__________-________-________
___________________
Child’s Full Name
Social Security Number
Date of Birth
(mm/dd/yyyy)
_________________________________________
__________-________-________
___________________
Child’s Full Name
Social Security Number
Date of Birth
(mm/dd/yyyy)
_________________________________________
__________-________-________
__________________
Child’s Full Name
Social Security Number
Date of Birth
(mm/dd/yyyy)
Section C – Designated Beneficiary
The following is the designation of a beneficiary eligible to receive my benefit(s), if payable.
_________________________________________
__________-________-________
__________________
Full Name
Social Security Number
Date of Birth
(mm/dd/yyyy)
Should I survive the above named beneficiaries, I request and authorize that such death benefits be paid to
my estate or to such other beneficiaries as I may hereafter designate in writing duly filed with the JRS, all in
accordance with the provisions of the JRS Law.
____________________________________________________________________________________________
Member’s Signature
Date
(mm/dd/yyyy)
PERS09M0301 DMC (11/10)
California Public Employees’ Retirement System
www.calpers.ca.gov
Privacy Notice
The privacy of personal information is of the utmost importance to CalPERS.
The following information is provided to you in compliance with the Information
Practices Act of 1977 and the Federal Privacy Act of 1974.
Information Purpose
Social Security numbers are used for the
following purposes:
The information requested is collected pursuant
1. Enrollee identification
to the Government Code (sections 20000 et seq.)
2. Payroll deduction/state contributions
and will be used for administration of Board
3. Billing of contracting agencies for employee/
duties under the Retirement Law, the Social
employer contributions
Security Act, and the Public Employees’ Medical
4. Reports to CalPERS and other state agencies
and Hospital Care Act, as the case may be.
5. Coordination of benefits among carriers
Submission of the requested information is
6. Resolving member appeals, complaints,
mandatory. Failure to comply may result in
or grievances with health plan carriers
CalPERS being unable to perform its functions
regarding your status.
Information Disclosure
Please do not include information that is
Portions of this information may be transferred
not requested.
to other state agencies (such as your employer),
physicians, and insurance carriers, but only
Social Security Numbers
in strict accordance with current statutes
regarding confidentiality.
Social Security numbers are collected on a
mandatory and voluntary basis. If this is CalPERS’
Your Rights
first request for disclosure of your Social Security
number, then disclosure is mandatory. If your
You have the right to review your membership
Social Security number has already been provided,
files maintained by the System. For questions
disclosure is voluntary. Due to the use of Social
about this notice, our Privacy Policy, or your rights,
Security numbers by other agencies for
please write to the CalPERS Privacy Officer at
identification purposes, we may be unable to
400 Q Street, Sacramento, CA 95811 or call us
verify eligibility for benefits without the number.
at 888 CalPERS (or 888-225-7377).
May 2016
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