- Designation of Beneficiary
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...
ERS - Beneficiary Form 
