Beneficiary Selection Form 2
Member’s Last Name First M.I. Social Security #
Choice of Option (D) Beneficiary
I, (Print Name) , a member of the
Retirement System, hereby nominate the beneficiary * listed below, under the provisions of G.L. c. 32, § 12(2)(d)
to receive from the retirement system a benefit equal to the Option (C) retirement allowance which would
otherwise have been payable to me in the event that I die before being retired.
I understand that I may change my beneficiary designation at any time prior to my retirement and that upon
my retirement this form becomes void.
I understand that this choice of Option D Beneficiary can be superceded if, at my death, I leave a spouse to
whom I have been married for over one year and with whom I am living on the date of my death, or if living
apart, for justifiable cause as determined by the Retirement Board.
Beneficiary
Name of Eligible Beneficiary Beneficiary’s Relationship to Member
Beneficiary’s Date of Birth (Attach birth record) Beneficiary’s Social Security #
Member
Member’s Signature __________________________________________ Date ___________
Member’s Street Address Member’s Social Security #
City/Town State Zip
To Be Completed by Witness of Choice of Option D Beneficiary
Witness’ Signature __________________________________________ Date ___________
Witness’ Name (Print)
* An eligible beneficiary is defined under G.L. c. 32, § 12(2)(d) as the spouse, former spouse who has not
remarried, child, father, mother, sister or brother of the member.
To Be Completed by Witness of Choice of Beneficiary of
Accumulated Total Deductions.
Signature of Witness __________________________________________ Date ____________
Name of Witness (Print) ______________________________________
