Beneficiary`s Consent Form for Changes under Section 13

BENEFICIARY’S CONSENT FORM FOR CHANGES
UNDER SECTION 13-565(c)
INSTRUCTIONS
PLEASE READ CAREFULLY
• P
lease complete this form only if both of the following are true: a) you are the beneficiary of a TRS
member who is receiving post-retirement payments under a payment option that does not allow
changes in beneficiary designation; and b) you consent to the member’s request to change his/her
payment option to the maximum allowance, as a result of divorce or dissolution of his/her relationship
with you.
• U
pon TRS’ processing of this form and the member’s “Change Form for Post-Retirement Payment
Option Under Section 13-565(c)” (code SD26), you would renounce your rights to beneficiary payments
based on the member’s retirement allowance under the Qualified Pension Plan (QPP) and/or annuity
under the Tax-Deferred Annuity (TDA) Program; consequently, no such benefits would be payable to
you from TRS as a result of the member’s death.
In Part A: All information must be provided.
In Part B: You must complete this part if you are consenting to the request of the member who is filing to remove you as
beneficiary of his/her Qualified Pension Plan (QPP) retirement allowance. You must sign and date this form.
In Part C: You must complete this part if you are consenting to the request of the member who is filing to remove you as
beneficiary of his/her Tax-Deferred Annuity (TDA) Program annuity. You must sign and date this form.
In Part D: You must have this form notarized.
SD27 (6/10) CONTINUED ON PAGE 2
PAGE 1
CONTINUED FROM PAGE 1
This page intentionally left blank.
SD27 (6/10) CONTINUED ON PAGE 3
PAGE 2
BENEFICIARY’S CONSENT FORM FOR CHANGES
UNDER SECTION 13-565(c)
Please read the instructions on page 1 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.
Beneficiary’s First Name
MI Last Name Beneficiary’s Permanent Home Address
XX X X X
Apt. No. Primary Phone Number (Check one:
(
City State Zip Code
TRS Member’s First Name
Social Security Number (last 4 digits only)
MI Last Name )
Alternate Phone Number (Check one:
(
)
Home
Home
Work
Work
Mobile)
Mobile
TRS Retirement Number
PART B: Please complete this part if you are consenting to the request of the above-named member, who is filing to change his/her
QPP retirement allowance payment option, consequently removing you as beneficiary.
I understand that _______________________________, a TRS member with retirement number ________________, has requested to
change his/her 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 am the designated QPP beneficiary of the above-named member, under retirement payment Option ____________,
and that I was his/her spouse or in contemplation of marriage with him/her when (s)he selected a payment option. Since then, I
have ceased to be his/her spouse, or am separated from him/her, or am no longer in contemplation of marriage with him/her. I have
read the “Change Form for Post-Retirement Payment Option Under Section 13-565(c)” (code SD26) completed by the above-named
individual, and I consent to the granting of the request explained therein.
I understand that, upon TRS’ processing of this form and the one named above, I will not be entitled to any survivor benefit under this
individual’s original option election for his/her QPP retirement allowance. I waive, release, and discharge the City of New York from
any and all claims, demands, or benefits that I may have, or become entitled to, as a result of my prior designation with the same force
and effect as if I had never been designated as beneficiary under his/her original election. I certify that have executed this form of my
own free will.
SIGNATURE _________________________________________________________ DATE (M/D/Y) ___________________________
SD27 (6/10) CONTINUED ON PAGE 4
PAGE 3
CONTINUED FROM PAGE 3
PART C: Please complete this part if you are consenting to the request of the above-named member, who is filing to change his/her
TDA annuity payment option, consequently removing you as beneficiary.
I understand that _______________________________, a TRS member with retirement number _________________, has requested
to change his/her TDA payment option to the Maximum Payment Option 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 am the designated TDA beneficiary of the above-named member, under payment Option ____________, and that I was
his/her spouse or in contemplation of marriage with him/her when (s)he selected a payment option. Since then, I have ceased to be
his/her spouse, or am separated from him/her, or am no longer in contemplation of marriage with him/her. I have read the “Change
Form for Post-Retirement Payment Option Under Section 13-565(c)” (code SD26) completed by the above-named individual, and I
consent to the granting of the request explained therein.
I understand that, upon TRS’ processing of this form and the one named above, I will not be entitled to any survivor benefit under this
individual’s original option election for his/her TDA annuity payment. I waive, release, and discharge the City of New York from any
and all claims, demands, or benefits that I may have, or become entitled to, as a result of my prior designation with the same force
and effect as if I had never been designated as beneficiary under his/her original election. I certify that have executed this form of my
own free will.
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:_ ____________________________________
SD27 (6/10) PAGE 4