Change Form for Post-Retirement Allowance Payment Option Under

CHANGE FORM FOR POST-RETIREMENT
Payment option under section 13-565(c)
INSTRUCTIONS
PLEASE READ CAREFULLY
• Y
ou may use this form to effect changes in your payment options for your retirement allowance under
the Qualified Pension Plan (QPP) (Tiers I/II only) and/or your annuity under the Tax-Deferred Annuity
(TDA) Program (all tiers). In all cases, you must have chosen Options II, III, IV-a, IV-2, IV-3, and IV-4 for
your payments.
• P
lease complete this form only if both of the following are true: a) you are receiving your postretirement payments under a payment option that provides for a beneficiary but does not allow you to
change your beneficiary designation; and b) you want to change your payment option to the Maximum
Payment Option as a result of a divorce or a dissolution of a relationship with the beneficiary.
• Y
ou must attach documents that provide legal proof of dissolution of relationship (e.g., court
documents, affidavits) to this form.
• P
lease note that receipt of this form does not constitute a valid filing unless your designated
beneficiary under the payment option also files a “Beneficiary’s Consent Form for Changes Under
Section 13-565(c)” (code SD27) with TRS.
• F
or your convenience, TRS forms and publications are available on our website. If you require
additional assistance, we encourage you to contact our Member Services Center at 1 (888) 8-NYC-TRS.
In Part A: All information must be provided.
In Part B: You must complete this part if you want to change your Qualified Pension Plan (QPP) retirement allowance
payment option to the maximum, and you had retired under one of the options listed above. You must sign and date this form.
In Part C: You must complete this part if you want to change your Tax-Deferred Annuity (TDA) Program annuity payment
option to the maximum, and you had elected a TDA annuity under one of the options listed above. You must sign and date
this form.
In Part D: You must have this form notarized.
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CHANGE FORM FOR POST-RETIREMENT
Payment option under section 13-565(c)
Please read the instructions before completing this form.
(NOTE: Please print in black or blue ink, and initial any changes that you make on this form.)
PART A: All information must be provided.
First Name
MI Last Name Permanent Home Address
City State Zip Code
Social Security Number (last 4 digits only)
XXX XX
Apt. No. TRS Retirement Number
Primary Phone Number (Check one:
(
)
Alternate Phone Number (Check one:
(
)
Home
Home
Work
Work
Mobile)
Mobile)
Please keep your personal information with TRS up to date. We will update our records based on the information you provide above,
so do not enter a temporary address; instead, TRS suggests that you consult the U.S. Postal Service about having your mail forwarded
on a temporary basis. To register any changes to your permanent address (and/or phone number), please access our website or file a
“Member’s Change of Address Form” (code DM13) with TRS.
If you are providing new information above, please indicate the effective date (M/D/Y):
PART B: If you want to change your QPP retirement allowance payment option to the maximum, and you had retired under one of the
options listed on page 1, please complete the following and sign and date below.
I hereby request to change my QPP retirement allowance payment option to the maximum retirement allowance, pursuant to Section
13-565(c) of the Administrative Code of the City of New York, which states the following:
“If the survivor beneficiary nominated [under a retirement payment option] is a spouse of the retired member, and such person
by causes other than death ceases to be his or her spouse or is separated from him or her, or if such option was selected in
contemplation of marriage which has not taken place, then [TRS] shall have authority to permit the change of the optional benefit
to the maximum benefit that is the actuarial equivalent by and with the consent of all parties.”
I certify that I retired on_________________________ and selected payment Option ____________ on the retirement application I filed.
(Month/Day/Year)
I designated _________________________________________________ as my beneficiary under this option. At the time of the
designation, (s)he was my spouse, or (s)he was so selected in contemplation of marriage. Since then, this beneficiary, by causes other
than death, ceased to be my spouse, or is separated from me, or is no longer in contemplation of marriage with me. I have attached
the pertinent legal documents that provide proof of the dissolution of this relationship.
_________________________________________________ has consented to the requested change by completing the “Beneficiary’s
Consent Form for Changes Under Section 13-565(c)” (code SD27), which is attached hereto. Therefore, I request permission to
change my QPP retirement allowance payment option to the Maximum Payment Option.
MEMBER’S SIGNATURE _________________________________________________ DATE (M/D/Y) _______________________
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PART C: If you want to change your TDA annuity payment option to the maximum, and you had elected a TDA annuity under one of
the options listed on page 1, please complete the following and sign and date below.
I hereby request to change my TDA annuity payment option to the maximum annuity, pursuant to Section 13-565(c) of the
Administrative Code of the City of New York, which states the following:
“If the survivor beneficiary nominated [under a TDA payment option] is a spouse of the retired member, and such person
by causes other than death ceases to be his or her spouse or is separated from him or her, or if such option was selected
in contemplation of marriage which has not taken place, then [TRS] shall have authority to permit the change of the
optional benefit to the maximum benefit that is the actuarial equivalent by and with the consent of all parties.”
I certify that I elected to annuitize my TDA funds under payment Option ____________ on the TDA annuitization form I filed.
I designated _________________________________________________ as my beneficiary under this option. At the time of the
designation, (s)he was my spouse, or (s)he was so selected in contemplation of marriage. Since then, this beneficiary, by causes
other than death, ceased to be my spouse, or is separated from me, or is no longer in contemplation of marriage with me. I have
attached the pertinent legal documents that provide proof of the dissolution of this relationship.
_________________________________________________ has consented to the requested change by completing the “Beneficiary’s
Consent Form for Changes Under Section 13-565(c)” (code SD27), which is attached hereto. Therefore, I request permission to
change my TDA annuity payment option to the Maximum Payment Option.
MEMBER’S SIGNATURE _________________________________________________ DATE (M/D/Y) _________________________
PART D: TO BE COMPLETED BY A NOTARY (NOTE: Attestation made outside the U.S. must be executed before an American consul.)
State of _____________________________ )
) s.s.:
County of _ __________________________ )
On the _______________ day of __________________________, __________, before me personally appeared the person
known to me to be ________________________________________________________________________________________, the
individual who executed the foregoing instrument and acknowledged to me that (s)he executed the same.
Signature: __________________________________________
Official Title: ________________________________________
Expiration Date of Commission: _________________________
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