Form PERS-BSD-1962 "Certification of Trust and Request for Continued Payment of Monthly Allowance to a Trust" - California

What Is Form PERS-BSD-1962?

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-1962 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-1962 "Certification of Trust and Request for Continued Payment of Monthly Allowance to a Trust" - California

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Certification of Trust and Request for Continued Payment
of Monthly Allowance to a Trust
888 CalPERS (or 888-225-7377) • TTY: (877) 249-7442
Complete this form only if you are the successor trustee(s) requesting that an annuitant’s monthly
benefit continue to be paid to the annuitant’s trust where the annuitant (or the annuitant and the
annuitant’s spouse) is the sole primary beneficiary during his or her lifetime. Review the last page
of this form for information and detailed instructions.
Annuitant's Information
Section 1
Information about
CalPERS ID
Annuitant's Name (First Name, Middle Initial, Last Name)
the annuitant.
(
)
Addr ess
Daytime Phone
Zip
Sta te
Cit y
Payment Preference
Section 2
I/We authorize CalPERS to send the annuitant's monthly allowance to the trust by:
 Direct Deposit (You must complete and submit a Direct Deposit Authorization form signed by the trustees.)
Please select one
 Paper Check (Provide mailing information below.)
box only.
Addr ess for Mailing of Check
Zip
Cit y
Sta te
Successor Trustee's Certification
Section 3
I/We,
wish to notify
Name of Successor Trustee(s)
,
California Public Employees' Retirement System (CalPERS) that as of
I/we became
Date
,
the successor trustee(s) of the
Name of Trust
.
dated
Date of Trust
Co-Trustee(s) (if applicable)
Beneficiary(ies) of Trust During Annuitant's Lifetime
Trust's Taxpayer Identification Number
Section 3 continues on page 2
PERS-BSD-1962 (rev. 09/2018)
Page 1 of 3
Certification of Trust and Request for Continued Payment
of Monthly Allowance to a Trust
888 CalPERS (or 888-225-7377) • TTY: (877) 249-7442
Complete this form only if you are the successor trustee(s) requesting that an annuitant’s monthly
benefit continue to be paid to the annuitant’s trust where the annuitant (or the annuitant and the
annuitant’s spouse) is the sole primary beneficiary during his or her lifetime. Review the last page
of this form for information and detailed instructions.
Annuitant's Information
Section 1
Information about
CalPERS ID
Annuitant's Name (First Name, Middle Initial, Last Name)
the annuitant.
(
)
Addr ess
Daytime Phone
Zip
Sta te
Cit y
Payment Preference
Section 2
I/We authorize CalPERS to send the annuitant's monthly allowance to the trust by:
 Direct Deposit (You must complete and submit a Direct Deposit Authorization form signed by the trustees.)
Please select one
 Paper Check (Provide mailing information below.)
box only.
Addr ess for Mailing of Check
Zip
Cit y
Sta te
Successor Trustee's Certification
Section 3
I/We,
wish to notify
Name of Successor Trustee(s)
,
California Public Employees' Retirement System (CalPERS) that as of
I/we became
Date
,
the successor trustee(s) of the
Name of Trust
.
dated
Date of Trust
Co-Trustee(s) (if applicable)
Beneficiary(ies) of Trust During Annuitant's Lifetime
Trust's Taxpayer Identification Number
Section 3 continues on page 2
PERS-BSD-1962 (rev. 09/2018)
Page 1 of 3
Put the annuitant's name
and CalPERS ID at the
top of every page.
Annuitant's Name
CalPERS ID
Successor Trustee's Certification, continued
Section 3,
continued
I/We have attached the following required documents:
 Verification that I/we was/were legally and properly appointed as successor trustee(s).
As successor trustee(s) of the above-named trust, I/we declare the following:
 I/We understand that CalPERS must be notified immediately upon the death of the annuitant, and
that monies paid to this trust after the date of death must be returned to CalPERS. As the
trustee(s), I/we assume responsibility for repayment of any monies to which CalPERS is entitled.
 All currently acting trustees of the trust have been identified in this Certification of Trust and have
signed this document.
 If there is more than one currently acting trustee, please select one of the checkboxes:
 Each trustee has the individual authority to act on behalf of the trust;
 All trustees must act unanimously on behalf of the trust; or
 Other (Please explain)
 The trust is still in effect. It has not been revoked, modified or amended in any manner
that would cause the representations contained in this Certification of Trust to be
incorrect.
 The annuitant or the annuitant and his or her spouse are the sole beneficiaries of the
trust during the annuitant's lifetime.
 I/We certify under penalty of perjury that all the information on this form is true and correct.
Signature(s) and
Date
Successor Trustee's Signature
date(s) required.
Phone
Address
Date
Co-Successor Trustee's Signature (if applicable)
Phone
Address
PERS-BSD-1962 (rev. 09/2018)
Page 2 of 3
Put the annuitant's name
and CalPERS ID at the top
of every page.
Annuitant's Name
CalPERS ID
Section 4
Notary Public Acknowledgment
A notary public or other officer completing this certificate verifies only the identity of the
Must be completed by
a notary public.
individual who signed the document to which this certificate is attached, and not the
truthfulness, accuracy, or validity of that document.
Separate notary
public
State of California, County of
acknowledgment
required if successor
On
before me,
trustees are not
Date
Name of Notary/Witness
appearing before the
same notary public at
personally appeared
, who proved to me on the basis of satisfactory
the same time.
evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and
acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies),
and that by his/her/ their signature(s) on the instrument the person(s), or the entity upon behalf of
which the person(s) acted, executed the instrument.
I certify under Penalty of Perjury under the laws of the State of California that the foregoing
paragraph is true and correct.
Notary Seal
Witness my hand and official seal.
Signature of Notary
Date (mm/dd/yyyy)
Print Name
CalPERS Benefit Services Division • P.O. Box 942711, Sacramento, California 94229-2711
Mail to:
PERS-BSD-1962 (rev. 09/2018)
Page 3 of 3
Certification of Trust and Request for Continued Payment of Monthly Allowance to a Trust
Information and Instructions
Information
Pursuant to Government Code 21256, a trustee of the trust shall have 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 a conservatorship is required if
changes other than the specified rights are requested by the successor trustee(s).
The successor trustee is responsible for reimbursing CalPERS for any monies CalPERS pays to the trust after
the annuitant’s death.
Annuitant's Information
Section 1
 The successor trustee must provide information regarding the annuitant who is the recipient
of the benefit payment.
Section 2
Payment Preference
 Select a checkbox to indicate how CalPERS should send the annuitant's 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
Successor Trustee's Certification
 Provide information regarding the trust.
 Attach written verification that you have been properly and legally appointed as successor
trustee. For example, attach copies of pages from trust document showing
successor trustee provisions and any additional documentation required by trust
document (e.g. trustee resignation, proof of incapacity, etc.).
 All currently acting trustees must sign and date this form.
 All signatures must be notarized.
Section 4
Notary Public Acknowledgment
 Must be completed by a notary public.
 Separate notary public acknowledgment required if successor trustees are not appearing
before the same notary public at the same time.
PERS-BSD-1962 (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
Page of 5