Form my|CalPERS0772 "Pre-retirement Lump-Sum Beneficiary Designation" - California

What Is Form my|CalPERS0772?

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 July 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 my|CalPERS0772 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|CalPERS0772 "Pre-retirement Lump-Sum Beneficiary Designation" - California

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Pre-Retirement Lump-Sum Beneficiary
Designation
888 CalPERS (or 888-225-7377) • TTY: (877) 249-7442 • Fax (800) 959-6545
Complete this form if you are currently employed (active) or an inactive member and you wish to designate a
beneficiary or change your existing beneficiary designation for lump-sum benefits. Please print clearly. We are
unable to process this form if there are erasures or corrections. See the information and instructions page for
more detailed information.
Information About You
Section 1
Please provide your
name as it appears
on your Social
Your Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
Security card.
(
)
(
)
Daytime Phone
Alternate Phone
Address
City
ZIP
State
Your Primary Beneficiary Information
Section 2
Please see the last
Name of Primary Beneficiary (First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
page of this form for
information on your
%
pre-retirement
Relationship to You
Percentage of Benefit
Social Security Number or CalPERS ID
benefits and
instructions on how
Address
to name more than
four primary
beneficiaries
State
City
ZIP
Name of Primary Beneficiary (First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
If a percentage is
entered, make sure
%
the total equals
Relationship to You
Percentage of Benefit
Social Security Number or CalPERS ID
100%.
Address
State
City
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
State
City
ZIP
Section 2 continues on page 2
my|CalPERS 0772 (rev.7/18)
1 of 4
Pre-Retirement Lump-Sum Beneficiary
Designation
888 CalPERS (or 888-225-7377) • TTY: (877) 249-7442 • Fax (800) 959-6545
Complete this form if you are currently employed (active) or an inactive member and you wish to designate a
beneficiary or change your existing beneficiary designation for lump-sum benefits. Please print clearly. We are
unable to process this form if there are erasures or corrections. See the information and instructions page for
more detailed information.
Information About You
Section 1
Please provide your
name as it appears
on your Social
Your Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
Security card.
(
)
(
)
Daytime Phone
Alternate Phone
Address
City
ZIP
State
Your Primary Beneficiary Information
Section 2
Please see the last
Name of Primary Beneficiary (First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
page of this form for
information on your
%
pre-retirement
Relationship to You
Percentage of Benefit
Social Security Number or CalPERS ID
benefits and
instructions on how
Address
to name more than
four primary
beneficiaries
State
City
ZIP
Name of Primary Beneficiary (First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
If a percentage is
entered, make sure
%
the total equals
Relationship to You
Percentage of Benefit
Social Security Number or CalPERS ID
100%.
Address
State
City
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
State
City
ZIP
Section 2 continues on page 2
my|CalPERS 0772 (rev.7/18)
1 of 4
Put your name and
Social Security number
or CalPERS ID at the
Your Name
Social Security Number or CalPERS ID
top of every page.
Your Primary Beneficiary Information, continued
Section 2
, cont
.
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
State
City
ZIP
Your Secondary Beneficiary Information
Section 3
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
%
to name more than
Relationship to You
Percentage of Benefit
Social Security Number or CalPERS ID
three secondary
beneficiaries.
Address
State
City
ZIP
Name of Secondary Beneficiary (First Name, Middle Initial, Last Name)
Birth Date (mm/dd/yyyy)
If a percentage (%)
is entered make
%
sure the total
Relationship to You
Percentage of Benefit
Social Security Number or CalPERS ID
equals 100%.
Address
State
City
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
State
City
ZIP
2 of 4
my|CalPERS 0772 (rev.7/18)
Put your name and Social
Security number or CalPERS
ID at the top of every page
Your Name
Social Security Number or CalPERS ID
Section 4
Spousal Consent to Beneficiary Designation
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 any lump sum benefits which 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 the following benefit (if
applicable):
The Group Term Life Insurance benefit.
The employer share benefit.
The return of any remaining member contributions.
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 fifty-percent (50%) 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 fifty-percent (50%) 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 on 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 the following benefit will be
paid to a beneficiary other than me in accordance with the beneficiary designation(s):
The Group Term Life Insurance benefit.
The employer share benefit.
The return of any remaining member contributions.
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
Your spouse or registered
that I have received a complete explanation of each benefit listed above (if applicable) and I
domestic partner should sign
have had the opportunity to consult with an attorney or other professional concerning this
this consent if he or she
waiver.
consents to each of your
beneficiary designations after
reviewing this section.
Your Spouse’s or Domestic Partner’s Signature
Date (mm/dd/yyyy)
3 of 4
my|CalPERS 0772 (rev.7/18)
Put your name and Social
Security number or CalPERS
ID at the top of every page
Name of Member
Social Security Number or CalPERS ID
Your Signature
Section 5
Before submitting your
I certify, under the penalty of perjury, that the information submitted hereon is true and correct to
completed form, be sure
the best of my knowledge.
to make a copy to keep
By this beneficiary designation, I hereby revoke any previous designation I have filed. I understand
with your important
that my marriage or domestic partnership, final dissolution or annulment of my marriage or the
retirement information.
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 domestic partnership
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
If no, please indicate:
Never Married or in Domestic Partnership
Divorced, Annulled, or Domestic Partnership Terminated
c
Widowed
c
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 6
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
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my|CalPERS 0772 (rev.7/18)
Pre-Retirement Lump-Sum Beneficiary Designation Information
Information
If you die before you retire, the Public Employees' Retirement Law provides for payment of specific benefits
to your surviving beneficiaries. Please order or download your Member Benefit Publication from our website
www.calpers.ca.gov or see your personnel officer for a description of the benefits. The benefits are payable
to the following beneficiaries:
A. If you are a safety member and your death is job-related, or if you are not a safety member but you are
fatally attacked while performing your official job duties, the Special Death Benefit may be payable. This
benefit is payable by law to your surviving spouse/registered domestic partner (whether or not you were
still living together at the time of your death) or, if none, to your unmarried children/step-children under age
22, whether or not you have filed a beneficiary designation.
B. If you are eligible for retirement or you are a State member with at least 20 years of State service credit,
a monthly survivor allowance may be payable. If you do not have a valid beneficiary designation on file,
the benefits will be payable to your surviving spouse/registered domestic partner to whom you have been
married to or in a partnership with for either one year or prior to the onset of the injury or illness that
resulted in death. Or, if there is no eligible surviving spouse/registered domestic partner, the allowance
will be payable to your unmarried minor children, if any.
If you do have a valid beneficiary designation on file, your spouse/registered domestic partner may still be
entitled to a community property share of your lump sum contributions or monthly survivor allowance.
However, your non-spouse/non-registered domestic partner designated beneficiaries will receive the portion
of your lump sum benefits that are not payable to your spouse/ registered domestic partner as his/her
community property share.
C. If A and B do not apply and there is no valid beneficiary designation on file at the time of death, the
benefits will be payable to your survivors in the following order:
1. Your surviving spouse/registered domestic partner (whether or not you were still living
together at the time of your death); or if none
2. Natural and adopted children, including (in limited situations) a natural child adopted by
another, share and share alike; or if none,
3. Parents, share and share alike; or if none,
4. Brothers and sisters, share and share alike, or if none,
5. Your estate (if probated, or subject to probate), or if not,
6. Your trust (if one exists), or if not,
7. Stepchildren, share and share alike or if none,
8. Grandchildren, including step-grandchildren, share and share alike, or if none,
9. Nieces and nephews, share and share alike, or if none,
10. Great-grandchildren, share and share alike, or if none,
11. Cousins, share and share alike.
If A and B do not apply and there is a valid beneficiary designation on file at the time of death, the benefits
will be payable to the beneficiary(ies) you designate on the form. However, if you are married or have a
registered domestic partner at the time of death, your spouse/registered domestic partner may
still be entitled to a community property share of your lump sum benefits.
D. You may designate or change your beneficiaries at any time by completing another Pre-Retirement Lump-Sum
Beneficiary Designation form. You may name as beneficiary any person or persons, a corporation or your
estate. Payment will be made to your estate only if probated. You may designate a trust as your beneficiary;
however, you must provide the name of the trust, the date of the trust, and the name and address where the trust
is filed. It is not necessary to provide the name of the trustee. Reminder: If you are married or in a registered
domestic partnership at the time of your death and you do not name your spouse/registered domestic
partner as beneficiary, he/she may still be entitled to a community property share of your lump sum
benefits or a share of any monthly survivor allowance that may be payable.
E. Your beneficiary designation will be revoked automatically, and benefits will be payable to the closest survivor
listed in section C, if any of the following events occur after your designation form is received by CalPERS:
1. Marriage/Registration of domestic partnership; or
2. Dissolution or annulment of your marriage/registered domestic partnership. However, a designation filed
after the initiation of a dissolution/annulment of marriage or registered domestic partnership is NOT
revoked when the dissolution/annulment is finalized; or
3. Birth or adoption of a child; or
4. Termination of membership that results in a refund of your contributions.
my|CalPERS 0772
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