Form PERS-BSD-1961 "Request for Payment of Monthly Allowance to a Trust" - California

What Is Form PERS-BSD-1961?

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 September 1, 2018;
  • 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 printable version of Form PERS-BSD-1961 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 PERS-BSD-1961 "Request for Payment of Monthly Allowance to a Trust" - California

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Request for Payment of Monthly Allowance to a Trust
888 CalPERS (or 888-225-7377) • TTY: (877) 249-7442
Complete this form only if you are requesting that a monthly benefit be paid to a trust where you (or you and
your spouse) are the sole beneficiary during your lifetime. Review the last page of this form for information
and detailed instructions.
Annuitant's Information
Section 1
CalPERS ID
Annuitant's Name (First Name, Middle Initial, Last Name)
(
)
Daytime Phone
Addr ess
Zip
Sta te
Cit y
Payment Preference
Section 2
I authorize CalPERS to send my monthly allowance to the trust by:
 Direct Deposit (You must complete and submit a Direct Deposit Authorization form.)
Please select one
 Paper Check (Provide mailing information below.)
box only.
Address for Mailing of Check
Zip
City
State
Annuitant's Certification
Section 3
authorize the California Public Employees'
I,
Annuitant's Name
Retirement System (CalPERS) to pay my monthly allowance to my trust as indicated in Section 2.
Name and Date of Trust
Co-Trustee(s) (if applicable)
Trust's Taxpayer Identification Number
I/We have attached the following required document:
 Certification of Trust for my trust agreement
Section 3 continues on page 2
PERS-BSD-1961 (rev. 09/2018)
Page 1 of 2
Request for Payment of Monthly Allowance to a Trust
888 CalPERS (or 888-225-7377) • TTY: (877) 249-7442
Complete this form only if you are requesting that a monthly benefit be paid to a trust where you (or you and
your spouse) are the sole beneficiary during your lifetime. Review the last page of this form for information
and detailed instructions.
Annuitant's Information
Section 1
CalPERS ID
Annuitant's Name (First Name, Middle Initial, Last Name)
(
)
Daytime Phone
Addr ess
Zip
Sta te
Cit y
Payment Preference
Section 2
I authorize CalPERS to send my monthly allowance to the trust by:
 Direct Deposit (You must complete and submit a Direct Deposit Authorization form.)
Please select one
 Paper Check (Provide mailing information below.)
box only.
Address for Mailing of Check
Zip
City
State
Annuitant's Certification
Section 3
authorize the California Public Employees'
I,
Annuitant's Name
Retirement System (CalPERS) to pay my monthly allowance to my trust as indicated in Section 2.
Name and Date of Trust
Co-Trustee(s) (if applicable)
Trust's Taxpayer Identification Number
I/We have attached the following required document:
 Certification of Trust for my trust agreement
Section 3 continues on page 2
PERS-BSD-1961 (rev. 09/2018)
Page 1 of 2
Put the annuitant's name
and CalPERS ID at the
top of every page.
Annuitant's Name
CalPERS ID
Annuitant's Certification, continued
Section 3,
continued
Should I become incapacitated, resign as trustee of my trust, or otherwise cease to act as trustee of
my trust, my successor trustee(s) must complete and submit the Certification of Trust and Request for
Continued Payment of Monthly Allowance to a Trust form. In addition, CalPERS will request from my
successor trustee(s) verification that the successor trustee(s) has been legally and properly appointed.
If I resign as trustee, I am aware I must provide a signed statement of resignation.
I understand that monies paid by CalPERS to this trust after my date of death must be returned to
CalPERS. My successor trustee(s) has been notified of his/her responsibility to notify CalPERS
immediately upon my death and of his/her obligation to repay any monies to which CalPERS is
entitled.
I certify that the above-named trust is a revocable living trust and I or I and my spouse are the sole
beneficiaries of this trust during my/our lifetime(s).
I certify under Penalty of Perjury that all the information on this form is true and correct.
Signature and
date required.
Date
Annuitant's Signature
CalPERS Benefit Services Division • P.O. Box 942711, Sacramento, California 94229-2711
Mail to:
PERS-BSD-1961 (rev. 09/2018)
Page 2 of 2
Request for Payment of Monthly Allowance to a Trust Information and Instructions
Information
If you establish a revocable living trust of which either you or you and your spouse are the sole beneficiaries
during your lifetime, CalPERS may pay your monthly allowance to that trust.
CalPERS can only pay a monthly allowance to a trust that was established for your benefit during your lifetime.
CalPERS cannot honor a request to have your monthly allowance paid to a trust for the benefit of another
person (e.g., a trust for the benefit of a grandchild). This is considered an assignment of benefits and is
prohibited by Government Code § 21255.
Should you become incapacitated or if you are otherwise no longer designated as the trustee of your trust,
your successor trustee(s) must complete and submit the Certification of Trust and Request for Continued
Payment of Monthly Allowance to a Trust form. In addition, your successor trustee(s) must provide written
verification that he or she has been properly appointed as successor trustee.
Pursuant to Government Code § 21256, the successor trustee(s) has the authority to make tax withholding
elections and to change the address for annuitant payments and payment-related correspondence.
Submission of a power of attorney that confers authority related to CalPERS or conservatorship is required if
changes to your account other than the those specified in Government Code § 21256 are requested by your
successor trustee(s).
The successor trustee(s) must reimburse any monies paid to the trust after your death.
It is recommended that you retain a copy of this form and keep it with the trust document.
Annuitant's Information
Section 1
 You must complete all fields.
Section 2
Payment Preference
 Select a checkbox to indicate how CalPERS should send your monthly allowance.
 If you select direct deposit, you must complete and sign the Direct Deposit Authorization
form.
 If you select paper check, provide the address for mailing of the check.
Section 3
Annuitant's Certification
 You must complete all fields, sign and date this form.
 You must attach the Certification of Trust from the trust agreement.
 If you are completing this form as an attorney-in-fact pursuant to a power of attorney
designation, you must submit a validly-executed and currently effective power of attorney
document with this form.
PERS-BSD-1961 (rev. 09/2018)
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