QPP Change of Beneficiary Form (code EN19)

QPP CHANGE OF BENEFICIARY FORM
UNDER OPTION I (MODIFIED OR UNMODIFIED) OR IV-B
INSTRUCTIONS
PLEASE READ CAREFULLY
When you retired under the Qualified Pension Plan, you elected a payment option for your retirement
allowance that provided for beneficiaries, whom you designated at that time. You may file this form to change
these beneficiaries and/or re-assign the percentage of the benefit that each beneficiary would receive.
The payment option that you elected provides you with monthly retirement allowance payments for life; then,
upon your death, your beneficiary(ies) would receive the remaining balance (under Option I*) or an amount
that you designated (under Option IV-b).
You may not change the following designations, which you may have made on your retirement application:
the payment method (i.e., lump sum or annuity) under any form of Option I, or the amount of the benefit under
Option IV-b.
• If benefits become payable, TRS may rely solely on any affidavit or other written evidence that it receives concerning
beneficiaries. Any payment that TRS makes based on this information will be a valid discharge of its obligations.
• The designations you make on this form will take effect as of the date of filing.
• You reserve the right to change, in a manner prescribed by TRS, any beneficiary designated herein.
• In the event that all designated beneficiaries have predeceased you, the death benefit will be paid to your estate.
*Note: Tier I members could have elected a “modified” or “unmodified” version of Option I; Tier II members were offered only one version of Option I.
You must complete all applicable parts of this form. As an alternative to filing this form, you may access the secure section
of our website.
In Part A: All information must be provided.
In Part B: You must designate your primary beneficiary(ies) under your lump-sum payment option, including all requested personal
information, and provide any other applicable information (i.e., percent of benefit, dollar amount of benefit). If you want to
designate more primary beneficiaries than space allows, you must complete Part D of this form.
In Part C: You must designate your contingent beneficiary(ies) under your lump-sum payment option, including all requested personal information, and provide any other applicable information (i.e., percent of benefit, dollar amount of benefit). If you
want to designate more contingent beneficiaries than space allows, you must complete Part D of this form.
In Part D: I_f you want to designate more beneficiaries than space allows, you must file a completed “Retired/Retiring Member’s Additional QPP Beneficiary Form” (code EN22) in conjunction with this form. (In an emergency situation, you may instead
attach a separate piece of paper with your name, Social Security number, and the names of your additional beneficiaries;
this document must be signed, dated, and notarized.)
For your convenience, TRS forms and publications are available on our website.
In Part E: You must write in your payment option and sign and date this form.
In Part F: You must have this form notarized.
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QPP CHANGE OF BENEFICIARY FORM
UNDER OPTION I (MODIFIED OR UNMODIFIED) OR IV-B
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: Please provide the information below.
First Name
MI Last Name Permanent Home Address
Social Security Number (last 4 digits only)
XX X X X
Apt. No. TRS Retirement Number
City State Zip Code
Email Address
Primary Phone Number (Check one:
(
)
Alternate Phone Number (Check one:
(
)
Home
Home
Work
Work
Mobile)
Mobile)
Check here if you entered new contact information above. TRS will then update our records based on what you entered.
Please keep your contact information up to date. You can visit our website to update your contact information anytime, or file a
“Member’s Change of Address Form” (code DM13) with TRS.
PART B: Please designate your primary beneficiary(ies) under your lump-sum payment option and provide all requested information.
You may write in a dollar amount only if you elected Option IV-b at retirement.
1. Primary Beneficiary’s First Name MI Last Name
Social Security Number
Home Address
Relationship to You
Date of Birth (MM/DD/YYYY)
City
Percent (if applicable) Dollar Amount (if applicable)
State
Zip Code
%
$
2. Primary Beneficiary’s First Name MI Last Name
Social Security Number
Home Address
Relationship to You
Date of Birth (MM/DD/YYYY)
City
Percent (if applicable) Dollar Amount (if applicable)
EN19 (2/16) State
Zip Code
%
CONTINUED ON PAGE 3
$
PAGE 2
CONTINUED FROM PAGE 2
3. Primary Beneficiary’s First Name MI Last Name
Social Security Number
Home Address
Relationship to You
Date of Birth (MM/DD/YYYY)
City
Percent (if applicable) Dollar Amount (if applicable)
State
Zip Code
%
$
PART C: Please designate your contingent beneficiary(ies) under your lump-sum payment option and provide all requested
information. You may write in a dollar amount only if you elected Option IV-b at retirement.
1. Contingent Beneficiary’s First Name MI Last Name Social Security Number
Home Address
City
State
Zip Code
Relationship to You
Date of Birth (MM/DD/YYYY)
Percent (if applicable) Dollar Amount (if applicable)
%
$
2. Contingent Beneficiary’s First Name MI Last Name Social Security Number
Home Address
City
State
Zip Code
Relationship to You
Date of Birth (MM/DD/YYYY)
Percent (if applicable) Dollar Amount (if applicable)
%
$
PART D: Please check the box below if necessary.
I would like to designate more beneficiaries than space allows in Part B and/or Part C. I have attached a completed
“Retired/Retiring Member’s Additional QPP Beneficiary Form” (code EN22) to this form.
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CONTINUED FROM PAGE 3
PART E: Please complete the following and sign below.
I certify that I am currently receiving a retirement allowance from TRS under Option _____________. In accordance with
the laws, rules, and regulations governing TRS, I hereby request that any benefits payable under this payment option be
paid after my death to the beneficiary(ies) that I list on this form. I understand that this filing will supersede all previous
beneficiary designations that I have made under this payment option.
MEMBER’S SIGNATURE _________________________________________ DATE (MM/DD/YYYY) _______________________
PART F: 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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