HomeMy WebLinkAbout30 Waiver of Spousal Right To Pension Benefits Form TAB 30
WAIVER OF SPOUSAL
RIGHT TO PENSION
BENEFITS FORM
CITY OF.LANSING
POLICE AND FIRE RETIREMENT SYSTEM
WAIVER OF SPOUSAL RIGHT TO PENSION BENEFITS FORM
Retirement System members who are married and who intend to designate a child, grandchild,parent,brother or
sister as a pension beneficiary must obtain spousal agreement evidenced by this completed and signed form
before such designation will be effective. If you are married and intend to designate a pension beneficiary other
than your spouse, the designation will not be effective unless your spouse voluntarily agrees to give up his or her
pension beneficiary rights and signs this form in Section II waiving his or her right to survivor pension benefits.
Return your completed fortn to the Human Resources Department and retain a copy for your records.
Incomplete forms are invalid. The Human Resources Department will forward the completed form to the
Retirement Office. The completed Waiver of Spousal Right To Pension Benefits Form must be on file with
the City of Lansing Retirement Office to be valid.
Section I. Member Information(Please Print or Type)
Members Name(Last,First,M.I.) Birthdate(M/D/YYYY)
Social Security Number
Spouse's Name (Last,First, M.I.) Spouse's Birthdate(M/D/YYYY)
Spouse's Social Security Number
Section II. Spousal Waiver
I, , understand that I am not required to sign this form but
that if I do so I forever give up and waive all my rights to receive pension benefits from the City of
Lansing Police and Fire Retirement System to which I am otherwise automatically entitled as the spouse
of a System member. I further understand and agree that by signing this form I waive my rights to receive
pension benefits so that my spouse may designate an alternative pension beneficiary and that pension benefits
will be paid to such alternative pension beneficiary and not to me.
Spouse's signature
STATE OF MICHIGAN)
)ss.
COUNTY OF INGHAM)
Subscribed and sworn to before me this day of ,20
Notary Public
County, Michigan
Acting in _ _ _ .� _ County, Michigan
My Commission expires:
Incomplete forms will be returned to your address listed above.
`Protected intonnation under the Michigan social security number protection act.