Do not alter this form or make stipulations. The use of correction fluid or other alterations on this form will render the

designation invalid.

To the Comptroller of the State of New York.

Designation of Primary Beneficiary(ies).

I hereby name the following benefciary(ies) to receive any ordinary death beneft payable on my behalf. If I have named more than

one benefciary, it is my intention that those living at the time of my death should share equally any beneft payable. I reserve the right to change this designation at any time.

RS 5127 (Rev. 11/11)

reverse

PRIMARY

1

Last Name

First Name

M.I.

Date of Birth

Month Day Year





 

Male

 

Female



Relationship (Fill in one circle)

 

Spouse



Parent



Child



Other

Address: Street

Apt. or Unit#

City

State

Zip Code





 

 









2

Last Name

First Name

M.I. Month Day Year





 

Male

 

Female



Relationship (Fill in one circle)

 

Spouse



Parent



Child



Other

Address: Street

Apt. or Unit#

City

State

Zip Code





 

 









3

Last Name

First Name

M.I. Month Day Year





 

Male

Female



Relationship (Fill in one circle)

 

 

Spouse



Parent



Child



Other

Address: Street

Apt. or Unit#

City

State

Zip Code





 









4

Last Name

First Name

M.I. Month Day Year





 

Male

 

Female



Relationship (Fill in one circle)

 

Spouse



Parent



Child



Other

Address: Street

Apt. or Unit#

City

State

Zip Code





 

 









Designation of Contingent Beneficiary(ies).

If all of the designated primary benefciaries die before I do, any ordinary death beneft payable on my behalf shall be paid to

the following. If I have named more than one benefciary, it is my intention that those living at the time of my death should share equally any beneft payable. Furthermore, if I

out-live these benefciaries, any beneft payable should be paid to my estate or any other benefciary I name thereafter. I reserve the right to change this designation at any time.

CONTINGENT

1

Last Name

First Name

M.I.

Date of Birth

Month Day Year

Male

Female

Relationship (Fill in one circle)

 

Spouse

Parent

Child

Other

Address: Street

Apt. or Unit#

City

State

Zip Code

2

Last Name

First Name

M.I. Month Day Year

Male

Female

Relationship (Fill in one circle)

 

Spouse

Parent

Child

Other

Address: Street

Apt. or Unit#

City

State

Zip Code

3

Last Name

First Name

M.I. Month Day Year

 

Male

Female

Relationship (Fill in one circle)

 

Spouse

Parent

Child

Other

Address: Street

Apt. or Unit#

City

State

Zip Code

4

Last Name

First Name

M.I. Month Day Year

Male

Female

Relationship (Fill in one circle)

 

Spouse

Parent

Child

Other

Address: Street

Apt. or Unit#

City

State

Zip Code

This form must be signed and notarized in order to be valid

Member’s Signature

Date

Acknowledgement To Be Completed by a Notary Public

State of _____________________________________________ County of ____________________________________________

On the ______ day of _________________ in the year _________ before me, the undersigned, personally appeared ____________________________, personally

known to me or proved to me on the basis of satisfactory evidence to be the individual(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 capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon

behalf of which the individual(s) acted, executed the instrument.

NOTARY PUBLIC (Please sign and affx stamp)