HomeMy WebLinkAbout29 Pre-Retirement Beneficiary Designation Form TAB 29
PRE-RETIREMENT
BENEFICIARY
DESIGNATION FORM
CITY OF LANSING
POLICE AND FIRE RETIRMENT SYSTEM
PRE-RETIREMENT BENEFICIARY DESIGNATION FORM
New hire Beneficiary change
Reason for change(supersedes ALL prior nomination forums)
Retirement system members must complete this form to designate pre-retirement beneficiaries. If you are married and
designate a pension beneficiary other than your spouse,the designation will not be effective unless your spouse agrees,
signs, and files a Waiver of Spousal Rights to Pension Benefits Form. Return your completed form to the Human
Resources Department and retain a copy for your records. The Human Resources Department will forward the
completed form to the Retirement Office. Your completed pre-retirement Beneficiary Designation Form must be
on file with the City of Lansing Retirement Office for the beneficiary designation to be valid.
Section I. Member Information(please print or type)
Member's Name(Last,First,M.1.) Social Security Number*
Street Address City,State,Zip Code
Birthplace(City, State) Birth date(M/D/YYYY) Male/Female
Spouse's Name("None" if unmarried) Spouse' Birth date(M/D/YYYY) Social Security Number*
Father's Name(if living) Birth date Mother's name(If living) Birth date
Section IL Pre-Retirement Beneficiary Nominations
A. Monthly Pension Beneficiary: You may nominate ONE person who is your spouse, child, grandchild,
parent,brother or sister to be paid a monthly survivor benefit if you are qualified to receive a pension and
die before you start to receive your retirement pension. The retirement plan does not allow you to name a
trust, estate or organization as the beneficiary.
Pension Beneficiary Name(Last,First,M.I.) Relationship Social Security Number* Birth date(M,'D/YYYY)
CAUTION: This Pension Beneficiary designation will not be effective and will automatically be void if any of the
following occur:
1. You designate a beneficiary who is not your spouse, child, grandchild,parent, brother, or sister.
2. You are unmarried when you make this designation and marry before you terminate your City
employment
3. You are married when you sign this form and you designate a beneficiary who is not your spouse but
your spouse has not agreed, signed and filed a Waiver of Spousal Rights to Pension Benefits Form,
4. Your death is a duty death under retirement ordinance Section 294.02(n).
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B. Accumulated Contribution Beneficiary: You may nominate ONE person to receive the lump sum refund
of your accumulated employee's contributions to the pension system in accordance with ordinance Section
294.02(q)(2)in the event you die before you start to receive a monthly retirement pension. This
designation will not be effective and is void if you are survived by someone who is entitled to receive a
monthly survivor pension benefit. Only an accumulated contribution beneficiary who survives you will be
entitled to receive the refund. You may nominate any person as your accumulated refund beneficiary.
You may also nominate here the person named in Section II. A. above.
Refund Beneficiary Name(Last,First,M.1.) Social Security Number* Birth date(M/DIYYYY)
Section III. Signature—I understand I may change my pre-retirement beneficiary nominations at any time before the
effective date of my retirement by filing a new Pre-Retirement Beneficiary Designation Form. This form when fully
completed and filed revokes all prior designation forms. If I am a married City employee, I understand that upon my
death my spouse is automatically my pension beneficiary unless my spouse has voluntarily signed and I have filed a
,Waiver of Spousal Right to Pension Benefit Form waiving the spousal rights to pension benefits. I declare to the best
of my knowledge and belief that all statements and answers on this form are full, accurate,complete, and true.
Member's Signature Date
Completion of this form is required. Incomplete forms will be returned to your address listed above.
*Protected information under the Michigan social security number protection act.
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