SURVIVOR BENEFICIARY DESIGNATION FORM >

PUBLIC EMPLOYEES RETIREMENT ASSOCIATION OF NEW MEXICO
PUBLIC EMPLOYEES RETIREMENT BOARD
P.O. Box 2123, Santa Fe, New Mexico 87504-2123
(505) 827-4670 fax (505) 827-4700 voice
www.state.nm.us/pera
… New form
… Change in existing information
SURVIVOR BENEFICIARY DESIGNATION FORM
Instructions: Please print or type in black. The original of this form must be completed in its entirety and returned to PERA
for processing. Required Fields are in BOLD ITALICS
MEMBER INFORMATION
PLEASE PRINT CLEARLY
DATE OF BIRTH (mm/dd/ccyy)
SOCIAL SECURITY NUMBER
FIRST NAME
ADDRESS TYPE
LAST NAME
MI
PERMANENT
TEMPORARY
MAILING HOME TELEPHONE NO.
ADDRESS
BUSINESS TELEPHONE NO.
EMAIL ADDRESS
CITY
STATE
ZIP
SEX
MALE
FEMALE
MARITAL STATUS
MARRIED
SINGLE
DIVORCED
WIDOWED
Marriage or divorce after the date this form is completed and submitted to PERA will affect your survivor beneficiary
designation. Please contact PERA if either event occurs.
BENEFICIARY INFORMATION
I hereby designate the person named below as my survivor beneficiary to receive a monthly pension payable for life in the
event of my death prior to retirement. I understand that if I have less than 5 years of service credit when I die, this monthly
pension will be payable only if my death is duty related. If I am married and designate someone other than my spouse as
survivor beneficiary, the spousal consent section of this form will be completed and signed by my spouse.
NAME
RELATIONSHIP
SSN
DATE OF BIRTH
ADDRESS/PHONE NUMBER
SPOUSAL CONSENT
I, ___________________________________ spouse of ________________________________________, consent to his/her
decision to designate _________________________________________________________ as a survivor beneficiary.
Signature of Member’s Spouse ________________________________________
Date: ______________________________
MEMBER AUTHORIZATION
I hereby declare that all the information provided is true and complete to the best of my knowledge and that the spousal
signature is the signature of my spouse
SIGNATURE OF MEMBER
DATE OF SIGNATURE (mm/dd/ccyy)
NOTARIZATION OF MEMBER’S SIGNATURE
State of New Mexico
)
)
County of
SS:
___________________ )
Subscribed and sworn to (or affirmed) before me by _____________________ on this the ______ day of _____________, _______.
My Commission Expires
__________________________
Notary Public
Telephone No: ______-______-_________
Notary Signature ___________________________________
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September 2004