With Contingent Beneficiaries For Active Members Only (not retirees) RS (Re5127v.11/11) Offce of the New York State Comptroller New York State and Local Retirement System Employees’ Retirement System Police and Fire Retirement System 110 State Street, Albany, New York 12244-0001 THIS FORM MUST BE SIGNED, NOTARIZED AND FILED WITH THE RETIREMENT SYSTEM PRIOR TO YOUR DEATH TO BE EFFECTIVE.
• New benefciary forms fled will supersede any previous designation.
The benefciaries entitled to receive accidental death
benefts are mandated by statute.
Please go to the reverse side of this form to designate beneficiaries, si...
Allowed
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EduTech School Districts 
