"Post-retirement Lump-Sum Beneficiary Designation" - California

Post-retirement Lump-Sum Beneficiary Designation is a legal document that was released by the California Public Employees' Retirement System - a government authority operating within California.

Form Details:

  • Released on August 1, 2017;
  • The latest edition currently provided by the California Public Employees' Retirement System;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the California Public Employees' Retirement System.

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Post-Retirement Lump-Sum Beneficiary
Designation
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
Complete this form if you are retired and you wish to designate a benefciary or change your existing benefciary
designation for lump-sum death benefts. For more information regarding lump-sum death benefts, refer to the
publication Changing Your Benefciary or Monthly Beneft After Retirement (PUB 98).
Please print clearly. We are unable to process this form if there are erasures or corrections. See the last page
of this form for detailed instructions.
Information About You
Section 1
Your Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
(
)
(
)
Daytime Phone
Alternate Phone
Address
City
State
ZIP
Your Benefciary Designation
Section 2
Select one of the choices below.
Please see the last
page of this form for
c
I want to name one or more benefciaries to receive an equal share or specifed percentage (%) of any payable
instructions on how
lump-sum death benefts in the event of my death.
to name different
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o r . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
benefciaries for each
payable lump-sum
c
I want to name separate benefciaries for each of the following payable lump-sum death benefts in the event
death beneft.
of my death:
c Retired Death Beneft
c Return of Remaining Contributions
c Temporary Annuity Balance
Your Primary Benefciary Information
Section 3
Please see the last
Name of Primary Beneficiary (First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
page of this form for
instructions on how
%
Relationship to You
Percentage of Benefit
Social Security Number or CalPERS ID
to name more than
four primary
benefciaries.
Address
If a percentage (%) is
City
State
ZIP
entered, make sure the
total equals 100%.
Name of Primary Beneficiary (First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
%
Relationship to You
Percentage of Benefit
Social Security Number or CalPERS ID
Address
City
State
ZIP
Section 3 continues on page 2.
PERSBSD509P (8/17)
Page 1 of 3
Post-Retirement Lump-Sum Beneficiary
Designation
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
Complete this form if you are retired and you wish to designate a benefciary or change your existing benefciary
designation for lump-sum death benefts. For more information regarding lump-sum death benefts, refer to the
publication Changing Your Benefciary or Monthly Beneft After Retirement (PUB 98).
Please print clearly. We are unable to process this form if there are erasures or corrections. See the last page
of this form for detailed instructions.
Information About You
Section 1
Your Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
(
)
(
)
Daytime Phone
Alternate Phone
Address
City
State
ZIP
Your Benefciary Designation
Section 2
Select one of the choices below.
Please see the last
page of this form for
c
I want to name one or more benefciaries to receive an equal share or specifed percentage (%) of any payable
instructions on how
lump-sum death benefts in the event of my death.
to name different
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o r . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
benefciaries for each
payable lump-sum
c
I want to name separate benefciaries for each of the following payable lump-sum death benefts in the event
death beneft.
of my death:
c Retired Death Beneft
c Return of Remaining Contributions
c Temporary Annuity Balance
Your Primary Benefciary Information
Section 3
Please see the last
Name of Primary Beneficiary (First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
page of this form for
instructions on how
%
Relationship to You
Percentage of Benefit
Social Security Number or CalPERS ID
to name more than
four primary
benefciaries.
Address
If a percentage (%) is
City
State
ZIP
entered, make sure the
total equals 100%.
Name of Primary Beneficiary (First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
%
Relationship to You
Percentage of Benefit
Social Security Number or CalPERS ID
Address
City
State
ZIP
Section 3 continues on page 2.
PERSBSD509P (8/17)
Page 1 of 3
Put your name and Social
Security number or CalPERS ID
Name of Member
Social Security Number or CalPERS ID
at the top of every page
Your Primary Benefciary Information, continued
Section 3,
continued
Name of Primary Beneficiary (First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
%
Relationship to You
Percentage of Benefit
Social Security Number or CalPERS ID
Address
City
State
ZIP
Name of Primary Beneficiary (First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
%
Relationship to You
Percentage of Benefit
Social Security Number or CalPERS ID
Address
City
State
ZIP
Your Secondary Benefciary Information
Section 4
Please see the last
Name of Secondary Beneficiary (First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
page of this form for
instructions on how
%
Relationship to You
Percentage of Benefit
Social Security Number or CalPERS ID
to name more than
three secondary
benefciaries.
Address
If a percentage (%) is
City
State
ZIP
entered, make sure the
total equals 100%.
Name of Secondary Beneficiary (First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
%
Relationship to You
Percentage of Benefit
Social Security Number or CalPERS ID
Address
City
State
ZIP
Name of Secondary Beneficiary (First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
%
Relationship to You
Percentage of Benefit
Social Security Number or CalPERS ID
Address
City
State
ZIP
PERSBSD509P (8/17)
Page 2 of 3
Put your name and Social
Security number or CalPERS ID
Name of Member
Social Security Number or CalPERS ID
at the top of every page
Your Acknowledgement and Signature
Section 5
Before submitting your
I understand that if I am married or in a registered domestic partnership and do not name my spouse or
completed form, be sure to
registered domestic partner as my benefciary for the return of any remaining contributions or temporary annuity
make a copy to keep
balance upon my death, he or she may still be entitled to receive his or her share of my community property
with your important
interest. If the marriage or partnership occurred after my retirement date, then my spouse or registered domestic
retirement information.
partner is not entitled to a community property interest.
Should I survive all of the persons named, I understand that the benefts payable upon my death will be paid to
my statutory benefciaries, or to such other benefciary or benefciaries that I may hereafter designate in writing
to CalPERS, all in accordance with applicable provisions of law.
By this benefciary designation, I hereby revoke any previous designation I have fled. I understand that my
marriage or domestic partnership, fnal dissolution or annulment of my marriage or the termination of my
domestic partnership, or the birth or adoption of a child subsequent to the date this form is fled with CalPERS
will automatically void this designation.
I understand that a designation fled after the initiation of dissolution or annulment of marriage or domestic
partnership or legal termination of domestic partnership will not be revoked when the legal process is fnalized.
Are you legally married or in a registered domestic partnership?
Yes
No
c
c
c
If yes, your spouse or registered domestic partner must sign this form if you did not name him or her
as the sole primary benefciary for all lump-sum death benefts.
If no, please indicate:
Never Married or in Domestic Partnership
c
Divorced, Annulled, or Domestic Partnership Terminated
c
Widowed
c
Your Signature
Date (mm/dd/yyyy)
Your Spouse’s or Registered Domestic Partner’s Signature
Section 6
If your spouse or
Per Government Code section 21261, I acknowledge that I am aware of the designation made by my spouse
registered domestic
or registered domestic partner. I also hereby state that I am the current spouse or registered domestic partner.
partner is unable to sign
this section, you must
Signature of Spouse or Registered Domestic Partner
Date (mm/dd/yyyy)
complete the Justifcation
for Absence of Spouse’s
or Registered Domestic
Date of Marriage or Registered Domestic Partnership (mm/dd/yyyy)
Partner’s Signature form.
Mail to:
CalPERS Beneft Services Division
P.O. Box 942711, Sacramento, California 94229-2711
PERSBSD509P (8/17)
Page 3 of 3
Information About You
Section 1
Complete all felds.
Your Benefciary Designation
Section 2
Select only one of the check boxes.
If you want to designate different benefciaries for the different types of lump-sum death benefts, you will
need to complete a new form for each type of designation. You can print a blank form from www.calpers.ca.gov,
make a copy of a blank Post-Retirement Lump-Sum Benefciary Designation form, or call us to request a new form.
Retired Death Beneft - The amount paid ranges from $500 to $5,000 depending on your employer’s contract with us.
Temporary Annuity Balance - If you elected to receive a temporary annuity when you retired and you die before your
temporary annuity payments stop, a lump-sum payment for the current value of the remaining payments will be paid.
Return of Remaining Contributions - Your remaining member contributions, if any, will be paid to your named
benefciary if you elected a retirement payment option that provides this beneft.
Your Primary Benefciary Information
Section 3
To name additional primary benefciaries, attach a blank sheet of paper with your additional benefciary information.
Provide the same benefciary information as required on this form and be sure to indicate that the benefciary is
primary. Sign and date the paper and include your Social Security number or CalPERS ID.
Your Secondary Benefciary Information
Section 4
The beneft you elected is paid to your named secondary benefciary upon the death of your primary benefciary
or benefciaries.
To name additional secondary benefciaries, attach a blank sheet of paper with your additional benefciary
information. Provide the same benefciary information as required on this form and be sure to indicate that the
benefciary is secondary. Sign and date the paper and include your Social Security number or CalPERS ID.
Your Acknowledgement and Signature
Section 5
Indicate if you are married or have a registered domestic partner.
Sign in the required feld.
Your Spouse’s or Registered Domestic Partner’s Signature
Section 6
Your spouse or registered domestic partner must sign if you did not designate him or her as the sole primary
benefciary for all lump-sum death benefts.
You must complete a Justifcation of Absence of Spouse’s or Registered Domestic Partner’s Signature
form if your spouse or registered domestic partner is unable to sign this form. You can print this form from
www.calpers.ca.gov or call 888 CalPERS (or 888-225-7377).
PERSBSD509P (8/17)
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
Page of 5