NET-11.4
(3/06)
NEW YORK STATE TEACHERS’ RETIREMENT SYSTEM
10 Corporate Woods Drive, Albany, NY 12211-2395
DESIGNATI ON OF BENE FICIARY
Last Name
First Name
M.I.
Social Security Number
Street
EmplID
City, State, Zip
Is this your permanent address?
Yes
?
No ?
I, the undersigned, revoking all former designations made by me pursuant to my death benefit coverage, hereby direct the NYS
Teachers’ Retirement System, in the event of my death, to pay the death benefit allowable on my account and the total of my
contributions, if any, in one lump sum payment to the beneficiary or beneficiaries named below. Should I survive all named
beneficiaries, any death benefit payable shall be paid to my estate.
Primary Beneficiaries
- If more than one primary beneficiary is named, the share of any beneficiary who dies before me shall be
divided equally among the surviving primary beneficiaries.
Contingent Beneficiaries
- Should I survive my primary beneficiary or beneficiaries, any benefit payable at my death shall be paid
in equal shares, unless otherwise indicated, to the surviving contingent beneficiary or beneficiaries.
Name
Check One
Check One
Date of Birth:
Primary
?
Male
?
Street
Contingent ?
Female ?
Relationship:
City, State, Zip
Beneficiary Soc Sec #
Name
Check One
Check One
Date of Birth:
Primary
?
Male
?
Street
Contingent ?
Female ?
Relationship:
City, State, Zip
Beneficiary Soc Sec #
Name
Check One
Check One
Date of Birth:
Primary
?
Male
?
Street
Contingent ?
Female ?
Relationship:
City, State, Zip
Beneficiary Soc Sec #
Name
Check One
Check One
Date of Birth:
Primary
?
Male
?
Street
Contingent ?
Female ?
Relationship:
City, State, Zip
Beneficiary Soc Sec #
BENEFICIARY INFORMATION
** This form must be signed and notarized in order to be valid **
Signature of
Telephone Number:
Applicant
State of _________________________________, County of ___________________________________________
On this _______ day of ___________________ in the year __________ before me, the undersigned, a Notary Public
in and for said State, personally appeared ____________________________________________________ , personally
known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed
to the within instrument, and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her
signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument.
Signature of Notary:
Expiration Date:
Please review the information on the reverse before mailing.
NYNY
SSTTRSRS
OFFICE
SERVICES ONLY
INSTRUCTIONS
FOR DESIGNATING A BENEFICIARY
1.
Please type or print in black or blue ink.
This form must be properly notarized
.
2.
Any number of primary and contingent beneficiaries may be named, but you must designate at least
one primary beneficiary.
The same person or persons cannot be designated as both primary and contingent
beneficiaries. We can make payment to a contingent beneficiary(ies) only if all primary beneficiaries die before
you do. If you survive all of the beneficiaries named, we would pay your estate.
3.
Any alterations to this form must be initialed.
Stipulations or attachments to your designation are not
acceptable.
4.
If you desire more beneficiaries than can fit on one form, you must use an additional designation form,
each clearly marked as "form 1 of 2" and "form 2 of 2," etc. Each form must be signed, notarized and
submitted at the same time.
Additional forms can be acquired from your employer, the System or downloaded
from our website at www.nystrs.org.
5.
New beneficiary forms filed will supersede any previous designation.
Therefore, if you want to add a
beneficiary, for example a new child, you must include on the new form all beneficiaries you wish to designate.
6.
If you designate persons:
?
List full names (e.g. Mary Smith not Mrs. John Smith). Unborn children may not be named.
?
Provide complete information requested for each beneficiary, including whether they are primary or contingent.
?
Beneficiaries should be listed separately (not Mr. and Mrs. on one line).
?
Do not
number your beneficiaries. Numbering of beneficiaries will result in an unclear
designation.
7.
If you designate your estate:
?
Use the words "My Estate" on the name line. Before naming your estate as beneficiary, we suggest you
contact the IRS or your tax advisor to determine the tax impact of such a designation.
?
If your estate is named as primary beneficiary, do not name a contingent beneficiary. A contingent
beneficiary would only be entitled to a benefit if the primary beneficiary ceases to exist before the member's
death.
8.
If you designate a corporation,
a copy of the certification of incorporation is required. Please be sure to use
the exact name of the corporation. If a religious organization is listed, we require a certificate of incorporation or
a charter.
9.
If you designate the trustee of an Intervivos Trust:
?
The trustee must be a person or a corporation
and a true copy of the trust instrument, or a Certificate
of Trust, containing the names and addresses of the trustee and successor trustees must be
submitted with your designation
.
?
The following sentence
must be
written in the beneficiary's name and address space on the front of this
form:
"(name of trustee), (address of trustee), as trustee of a trust created by instrument, dated
(date of instrument), a true copy of which is annexed hereto."
10.
If you designate the trustee of a Testamentary Trust:
?
The will under which the trust is established must be your will.
?
The following sentence
must be
written in the beneficiary's name and address space on the front of this
form:
"The trustee of the testamentary trust established by paragraph (number) of my will, dated
(date of your will)."
11.
If you designate a custodian for a minor:
?
The following sentence
must be
written in the beneficiary's name and address space on the front of this
form:
"(name and address of custodian) as custodian for (minor's name) under the New York
Uniform Transfers to Minors Act." The sex, date of birth, relationship and Social Security number
refer to the minor, not the custodian.
BENEFICIARY DESIGNATION CHECK LIST
?
Is your designation form
signed
and
notarized?
?
Did you write your social security number in the appropriate box on the reverse?
?
Did you designate at least one primary beneficiary?
?
Did you initial any changes, whiteouts or erasures you may have made?
?
If you indicated percentages for your primary or contingent beneficiaries, do the percentages equal 100%?
IN ORDER FOR YOUR NEW DESIGNATION TO BE ACCEPTABLE, IT MUST BE COMPLETED PROPERLY, NOTARIZED, SIGNED
AND RECEIVED BY THE SYSTEM. IF YOU HAVE ANY QUESTIONS WHEN COMPLETING THIS FORM, PLEASE CALL US AT
1-800-348-7298, EXT. 6130.