Form my|CalPERS0776 "Post-retirement Nonmember Lump-Sum Beneficiary Designation" - California

What Is Form my|CalPERS0776?

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 December 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 fillable version of Form my|CalPERS0776 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 my|CalPERS0776 "Post-retirement Nonmember Lump-Sum Beneficiary Designation" - California

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Post-Retirement Nonmember Lump-Sum
Beneficiary Designation
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
If you receive a monthly benefit as part of a community property settlement, complete this form if you wish
to designate a beneficiary or change your existing beneficiary designation for lump-sum benefits. For more
information regarding lump-sum benefits, refer to the publication Changing Your Beneficiary or Monthly Benefit
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 Lump-Sum Benefit Type
Section 2
Select one of the check boxes below.
Please see the last page
of this form for
c
I want to name one or more beneficiaries to receive an equal share or specified percentage (%) of any payable
instructions on how
lump-sum benefits in the event of my death.
to name different
beneficiaries for
c
I want to name separate beneficiaries for each of the following payable lump-sum benefits in the event
each payable
of my death:
lump-sum benefit.
c Prorated Allowance
c Return of Remaining Contributions
Your Primary Beneficiary 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
%
to name more than
Relationship to You
Percentage of Benefit
Social Security Number or CalPERS ID
four primary
beneficiaries.
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.
my|CalPERS0776 (12/18)
Page 1 of 3
Post-Retirement Nonmember Lump-Sum
Beneficiary Designation
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
If you receive a monthly benefit as part of a community property settlement, complete this form if you wish
to designate a beneficiary or change your existing beneficiary designation for lump-sum benefits. For more
information regarding lump-sum benefits, refer to the publication Changing Your Beneficiary or Monthly Benefit
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 Lump-Sum Benefit Type
Section 2
Select one of the check boxes below.
Please see the last page
of this form for
c
I want to name one or more beneficiaries to receive an equal share or specified percentage (%) of any payable
instructions on how
lump-sum benefits in the event of my death.
to name different
beneficiaries for
c
I want to name separate beneficiaries for each of the following payable lump-sum benefits in the event
each payable
of my death:
lump-sum benefit.
c Prorated Allowance
c Return of Remaining Contributions
Your Primary Beneficiary 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
%
to name more than
Relationship to You
Percentage of Benefit
Social Security Number or CalPERS ID
four primary
beneficiaries.
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.
my|CalPERS0776 (12/18)
Page 1 of 3
Put your name and Social
Security number or CalPERS ID
Name of Nonmember
Social Security Number or CalPERS ID
at the top of every page
Your Primary Beneficiary 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 Beneficiary 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
beneficiaries.
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
my|CalPERS0776 (12/18)
Page 2 of 3
Put your name and Social
Security number or CalPERS ID
Name of Nonmember
Social Security Number or CalPERS ID
at the top of every page
Your Acknowledgement and Signature
Section 5
Before submitting your
Should I survive all of the persons named, I understand that the benefits payable upon my death will be
completed form, be sure to
paid to my statutory beneficiaries, or to such other beneficiary or beneficiaries that I may hereafter designate
make a copy to keep
in writing to CalPERS, all in accordance with applicable provisions of law.
with your important
By this beneficiary designation, I hereby revoke any previous designation I have filed. I understand that my
retirement information.
marriage or domestic partnership, final 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 filed with CalPERS
will automatically void this designation.
Your Signature
Date (mm/dd/yyyy)
Mail to:
CalPERS Benefit Services Division
P.O. Box 942711, Sacramento, California 94229-2711
my|CalPERS0776 (12/18)
Page 3 of 3
Post-Retirement Nonmember Lump-Sum Beneficiary Designation —
Instructions for Completing Form
Information About You
Section 1
Complete all fields.
Your Lump-Sum Benefit Type
Section 2
Select only one of the check boxes.
If you want to designate different beneficiaries for the different types of lump-sum benefits, 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 Nonmember Lump-Sum Beneficiary Designation form, or call us
to request a new form.
Prorated Allowance - This is a lump-sum payment equal to your retirement allowance divided by the number
of days in the month of your death, then multiplied by the number of days you lived.
Return of Remaining Contributions - Your remaining member contributions, if any, will be paid to your named
beneficiary if you elected a retirement payment option that provides this benefit.
Your Primary Beneficiary Information
Section 3
To name additional primary beneficiaries, attach a blank sheet of paper with your additional beneficiary information.
Provide the same beneficiary information as required on this form and be sure to indicate that the beneficiary is
primary. Sign and date the paper and include your Social Security number or CalPERS ID.
Your Secondary Beneficiary Information
Section 4
The benefit you elected is paid to your named secondary beneficiary upon the death of your primary beneficiary
or beneficiaries.
To name additional secondary beneficiaries, attach a blank sheet of paper with your additional beneficiary
information. Provide the same beneficiary information as required on this form and be sure to indicate that the
beneficiary is secondary. Sign and date the paper and include your Social Security number or CalPERS ID.
Your Acknowledgement and Signature
Section 5
Sign in the required field.
my|CalPERS0776 (12/18)
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