Death Benefit Payment Option Selection Form (BEN-66)

COMMONWEALTH OF PENNSYLVANIA
STATE EMPLOYEES' RETIREMENT SYSTEM
30 NORTH THIRD ST STE 150
HARRISBURG, PA 17101-1716
1-800-633-5461
www.sers.state.pa.us
Member
: JOHN Q. PUBLIC
Beneficiary : JANE Q. PUBLIC
Soc Sec No: 123-45-6789
Soc Sec No: 987-65-4321
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As the named beneficiary you may elect to receive payment under any of the options listed below.
Please read carefully the explanation of ALL available choices before making your selection. The type
of payment cannot be changed once a selection has been made.
Make your selection by completing the enclosed application, including the affidavit. Return the completed
selection form and any other required forms to this office as soon as possible. The selection must be
completed before your payment can be processed.
A. LUMP SUM PAYMENT OF $xxx,xxx.xx
If you prefer to receive a portion of Option "A" by lump sum payment and the balance, which may not
be less than $10,000.00, in monthly payments, please advise us and we will furnish you with the
amounts payable.
PORTION OF OPTION "A" BY LUMP SUM PAYMENT: $xxx,xxx.xx
REMAINING BALANCE OF LUMP SUM PAYMENT: $xxx.xxx payable through following options :
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B. LIFE ANNUITY OF $xxx.xx per month
A monthly annuity in this amount will be paid throughout your lifetime, all payments will cease at your
death.
C. LIFE ANNUITY (TEN-YEAR GUARANTEE) OF $xxx.xx per month
A monthly annuity in this amount will be paid throughout your lifetime. If your death should occur
sooner than ten (10) years from the effective date, any remaining balance will be paid to your estate in
a lump sum settlement.
D. CASH REFUND ANNUITY OF $xxx.xx per month
A monthly annuity in this amount will be paid throughout your lifetime. If your death should occur
before you receive the equivalent of the lump sum payable under Option "A", any remaining balance
will be paid to your estate in a lump sum settlement.
E. TERM-CERTAIN ANNUITY
A monthly amount will be paid to you for a period of 1 to 20 years, whichever you choose, after which
all payments will cease. If your death should occur before the end of the term you choose, any
remaining balance will be paid to your estate in a lump sum settlement. To estimate the amount of
your term-certain annuity, please use the following instructions:
1. Find the factor from the table on the following page for the number of year(s) you wish to receive an
annuity.
2. Multiply the REMAINING BALANCE OF LUMP SUM PAYMENT by this factor.
3. The result is your monthly payment amount.
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Table of Factors for 1 to 20 years
0.085117
0.015612
0.009342
0.007023
2) 0.043393
7) 0.013635
12) 0.008720
17) 0.006727
3) 0.029492
8) 0.012156
13) 0.008196
18) 0.006465
4) 0.022547
9) 0.011007
14) 0.007748
19) 0.006231
5) 0.018384
10) 0.010090
15) 0.007361
20) 0.006022
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1)
6)
11)
16)
If you choose this type of payment, SERS will calculate the authorized term-certain amount upon receipt
of your selection. If your estimated amount differs from SERS by 5% or more, we will send you
notification and another application to complete.
If you select a monthly benefit option, your payments will begin 03/01/2008
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Please contact the Benefits Determination Division at 1-800-633-5461 ext. 7316 with any questions.
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DEATH BENEFIT PAYMENT OPTION SELECTION FORM
Member : JOHN Q. PUBLIC
Beneficiary :JANE Q. PUBLIC
Soc Sec No: 123-45-6789
Soc Sec No: 987-65-4321
Please place an 'X' beside the Death Benefit Payment Option you have chosen and complete the
affidavit. The form must be notarized in order for payment to be processed. Please note that the type of
payment cannot be changed after the selection has been made.
A. LUMP SUM PAYMENT OF $xxx,xxx.xx
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I have chosen a partial lump sum payment of $xxx,xxx.xx with a REMAINING BALANCE OF LUMP
SUM PAYMENT: $x.xx payable through the following option:
B. LIFE ANNUITY OF $xxx.xx per month
C. LIFE-ANNUITY (TEN-YEAR GUARANTEE) OF $xxx.xx per month
D. CASH REFUND ANNUITY OF $xxx.xx per month
E. TERM CERTAIN ANNUITY
_________________________
Estimated Monthly Annuity
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_______________
Number of Years
AFFIDAVIT
State of ___________________
County of ____________________
Before me, a __________________________ in and for the State of __________________,
personally appeared ______________________________________, who being duly sworn according to
law, deposes and says that he/she is the beneficiary named here in and further deposes and says that
his/her date of birth is ____________ to the best of his/her knowledge, information, and belief.
________________________
Signature of Applicant
Sworn to and subscribed before me
this ________________day of
_________________, _______
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_________________________
Signature of Notary Public
_________________________
Date Commission Expires