Form PERS-BSD-509P "Post-retirement Lump-Sum Beneficiary Designation" - California

What Is Form PERS-BSD-509P?

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 February 1, 2019;
  • 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 PERS-BSD-509P 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-509P "Post-retirement Lump-Sum Beneficiary Designation" - California

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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 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. Select the benefit type that applies to you:
lump-sum benefit.
c Retired Death Benefit
c Return of Remaining Contributions
c Temporary Annuity Balance
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
%
Relationship to You
Percentage of Benefit
Social Security Number or CalPERS ID
to name more than
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.
PERSBSD509P (2/19)
Page 1 of 4
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 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. Select the benefit type that applies to you:
lump-sum benefit.
c Retired Death Benefit
c Return of Remaining Contributions
c Temporary Annuity Balance
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
%
Relationship to You
Percentage of Benefit
Social Security Number or CalPERS ID
to name more than
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.
PERSBSD509P (2/19)
Page 1 of 4
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 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
PERSBSD509P (2/19)
Page 2 of 4
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
Spousal Consent to Beneficiary Designation
Section 5
You must review and sign this acknowledgment if you are married or in a registered domestic partnership and
you name someone other than your spouse or domestic partner as a beneficiary to receive an ongoing monthly
benefit or any lump-sum benefits that may be payable upon your death.
Member Acknowledgment
I understand that if I am married or in a registered domestic partnership, my spouse or domestic partner
may have community property rights in one or more of the following benefits (if applicable):
The monthly option benefit that continues following a member’s death;
The return of any remaining member contributions; and/or
The Retired Death Benefit.
If I name someone other than my spouse or domestic partner as my beneficiary for some or all of these benefits
and I die before my spouse or domestic partner, he or she may still be entitled to receive his or her community
property share of the benefit(s). If I name one or more other individuals as my beneficiary(ies) to receive a benefit
listed above, and my spouse or domestic partner does not consent at this time by signing below, CalPERS will
award 50 percent of the community property share of such benefit to my spouse or domestic partner in the
event of my death unless he or she waives his or her community property interest in such benefit at the time the
benefit becomes payable, and CalPERS will award the remaining 50 percent of the community property share,
plus any separate property share, of such benefit to the named beneficiary(ies).
Your Signature
Date (mm/dd/yyyy)
Spouse’s or Registered Domestic Partner’s Consent
I hereby voluntarily and irrevocably consent to each of the beneficiary designation(s) by my spouse/registered
domestic partner in this form. I acknowledge and understand that I am not obligated to consent and, if I do
consent, and my spouse or registered domestic partner dies before me and has named a beneficiary other
than me, some or all of the following benefits will be paid to a beneficiary other than me in accordance with
the beneficiary designation(s):
The monthly option benefit that continues following a member’s death;
The return of any remaining member contributions; and/or
The Retired Death Benefit.
I understand that I may have community property or other rights in these benefits, and I hereby voluntarily
waive and release any rights I may have to these benefits. I understand that I do not have to sign this consent
and that if I do sign my consent is irrevocable. I acknowledge that I have received a complete explanation of
each benefit listed above (if applicable), and I have had the opportunity to consult with an attorney or other
professional concerning this waiver.
Your spouse or registered
Your Spouse’s or Domestic Partner’s Signature
Date (mm/dd/yyyy)
domestic partner should
sign this consent if he or
she consents to each of your
beneficiary designations after
reviewing this section.
PERSBSD509P (2/19)
Page 3 of 4
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 Signature
Section 6
Before submitting your
I certify, under penalty of perjury, that the information submitted hereon is true and correct to the best
completed form, be sure to
of my knowledge.
make a copy to keep
Should I survive all of the persons named, I understand that the benefits payable upon my death will be
with your important
paid to my statutory beneficiaries, or to such other beneficiary or beneficiaries that I may hereafter designate
retirement information.
in writing to CalPERS, all in accordance with applicable provisions of law.
By this beneficiary designation, I hereby revoke any previous designation I have filed. I understand that
my 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.
I understand that a designation filed after the initiation of dissolution or annulment of marriage or legal
termination of domestic partnership will not be revoked when the legal process is finalized.
Are you legally married or in a registered domestic partnership?
Yes
No
c
c
c
If no, please indicate:
c
Never Married or in Domestic Partnership
c
Divorced, Annulled, or Domestic Partnership Terminated
c
Widowed
If you answered yes above, your spouse or registered domestic partner must sign this beneficiary designation
unless you have designated him or her as the sole primary beneficiary of any lump-sum benefits. Otherwise,
you must complete and submit the Justification for Absence of Spouse’s or Registered Domestic
Partner’s Signature form.
Your Signature
Date (mm/dd/yyyy)
Your Spouse’s or Registered Domestic Partner’s Signature
Section 7
Per Government Code section 21261, I acknowledge that I am aware of the designation made by my spouse
or registered domestic partner. I also hereby state that I am the current spouse or registered domestic partner.
Signature of Spouse or Registered Domestic Partner
Date (mm/dd/yyyy)
Date of Marriage or Registered Domestic Partnership (mm/dd/yyyy)
Mail to:
CalPERS Benefit Services Division
P.O. Box 942711, Sacramento, California 94229-2711
PERSBSD509P (2/19)
Page 4 of 4
Post-Retirement 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 Lump-Sum Beneficiary Designation form, or call us to request a new form.
Retired Death Benefit - The amount paid ranges from $500 to $5,000 depending on your employer’s contract with us.
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.
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.
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.
Spousal Consent to Beneficiary Designation
Section 5
If you did not name your spouse or registered domestic partner as your lump-sum beneficiary, you must
read and sign the Member Acknowledgment. Your spouse or registered domestic partner must read the
Spouse’s or Registered Domestic Partner’s Consent.
Your Signature
Section 6
Indicate if you are married or in a registered domestic partnership.
Sign in the required field.
Your Spouse’s or Registered Domestic Partner’s Signature
Section 7
Your spouse or registered domestic partner must sign if you did not designate him or her as the sole
primary beneficiary for any lump-sum benefits.
You must complete a Justification 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 (2/19)
Page of 6