Form my|CalPERS0774 "Pre-retirement Nonmember Lump-Sum Beneficiary Designation" - California

What Is Form my|CalPERS0774?

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 May 1, 2016;
  • 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|CalPERS0774 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|CalPERS0774 "Pre-retirement Nonmember Lump-Sum Beneficiary Designation" - California

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Pre-Retirement Nonmember Lump-Sum
Beneficiary Designation
888 CalPERS (or 888-225-7377) • TTY: (877) 249-7442 • Fax (800) 959-6545
Complete this form if you have a separate non-member account and you wish to designate a beneficiary or
beneficiaries other than the statutory beneficiaries, to receive the accumulated contributions and interest payable
upon your death prior to retirement.
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
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
Birth Date (mm/dd/yyyy)
Member's Name (First Name, Middle Initial, Last Name)
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
nonmember death
benefit and
Address
instructions on how
to name more than
three primary
State
City
ZIP
beneficiaries
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
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
my|CalPERS 0774
1 of 3
Pre-Retirement Nonmember Lump-Sum
Beneficiary Designation
888 CalPERS (or 888-225-7377) • TTY: (877) 249-7442 • Fax (800) 959-6545
Complete this form if you have a separate non-member account and you wish to designate a beneficiary or
beneficiaries other than the statutory beneficiaries, to receive the accumulated contributions and interest payable
upon your death prior to retirement.
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
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
Birth Date (mm/dd/yyyy)
Member's Name (First Name, Middle Initial, Last Name)
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
nonmember death
benefit and
Address
instructions on how
to name more than
three primary
State
City
ZIP
beneficiaries
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
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
my|CalPERS 0774
1 of 3
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 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
two 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
Your Acknowledgment and Signature
Section 4
I understand that if I survive all of the person(s) named above, that the accumulated contributions and interest
payable upon my death prior to retirement, will be paid to my statutory beneficiaries, or to such other beneficiary
Before submitting
or beneficiaries that I may hereafter designate in writing to the Board of Administration, in accordance with the
your completed form,
applicable provisions of law.
be sure to make a
copy to keep with
I hereby revoke any previous designation that I have filed. I understand that my marriage or legal registration of
your important
domestic partnership, the initiation of dissolution or annulment of my marriage, or legal termination of registered
retirement
domestic partnerships, or the birth of my child, or my adoption of a child subsequent to the date I file this form
information.
with CalPERS, will automatically void this designation.
Your Signature
Date (mm/dd/yyyy)
CalPERS Benefit Services Division  P.O. Box 942711 Sacramento, CA 94229-2711
Mail to:
my|CalPERS 0774
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Pre-Retirement Nonmember Lump-Sum Beneficiary Designation Information
Information
This beneficiary designation form should only be used by a former spouse of a member or a registered
domestic partner of a member who has a separate non-member account and who wishes to designate a
beneficiary or beneficiaries other than the statutory beneficiaries defined below, to receive the
accumulated contributions and interest payable upon their death prior to retirement. Please note that the
accumulated contributions and interest are available only if you die before you have received these
funds. Note: If you choose to retire and receive a monthly allowance, you will have the right to make
option selections and designate beneficiaries at that time.
You may name as beneficiary any person, a corporation, or your estate. Payment cannot be made to
an estate that is not probated. You may designate a trust as your beneficiary; however, you should
provide the name of the trust and the name and address where the trust is filed. We ask you not to
designate the trustee by name as this is subject to change. You may also designate persons by group
or class (for example, "children" or "grandchildren").
Your Non-Member Beneficiary Designation will be revoked automatically if any of the following
events occur after your beneficiary designation is received by CalPERS:
1. Your marriage or registration of domestic partnership,
2. The initiation of a dissolution or annulment of marriage, or legal termination of a registered
domestic partnership; however, a designation filed after the initiation of a dissolution or
annulment or termination of a registered domestic partnership is NOT revoked when the
dissolution/annulment/termination is finalized,
3. The birth of your child and/or adoption of a child.
If there is no valid beneficiary designation on file at the time of your death, the accumulated contributions
and interest 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,
2. Your natural and adopted children,
3. Your brothers and sisters,
4. Your estate, if probated,
5. Your Trust.
Pre-Retirement Nonmember Lump-Sum Beneficiary Designation Instructions
Information About You
Section 1
 Complete all fields.
Your Primary Beneficiary Information
Section 2
 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 3
 The benefit 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 4
 Sign in the required field.
my|CalPERS 0774
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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
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