Fillable ACTIVE DEFERRED BENEFICIARY CHANGE

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ACTIVE DEFERRED BENEFICIARY CHANGE

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The ACTIVE DEFERRED BENEFICIARY CHANGE form is 2 pages long and contains:

  • 3 signatures
  • 6 check-boxes
  • 89 other fields

Country of origin: OTHERS
File type: PDF

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Beneficiary Designation
Type or print in ink.
SECTION 1: MEMBER INFORMATION
FIRST NAME:
MI:
LAST NAME:
SEX:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
MAILING ADDRESS:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
EMAIL ADDRESS:
MARITAL STATUS:
EMPLOYER:
DEPARTMENT:
SECTION 2: BENEFICIARY INFORMATION
BENFICIARY #1
FIRST NAME:
MI:
LAST NAME:
SEX:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENEFIT PERCENT:
MAILING ADDRESS:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
E-MAIL ADDRESS:
RELATIONSHIP:
BENFICIARY #2
FIRST NAME:
MI:
LAST NAME:
SEX:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENEFIT PERCENT:
MAILING ADDRESS:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
E-MAIL ADDRESS:
RELATIONSHIP:
BENFICIARY #3
FIRST NAME:
MI:
LAST NAME:
SEX:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENEFIT PERCENT:
MAILING ADDRESS:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
E-MAIL ADDRESS:
RELATIONSHIP:
BENFICIARY #4
FIRST NAME:
MI:
LAST NAME:
SEX:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENEFIT PERCENT:
MAILING ADDRESS:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
E-MAIL ADDRESS:
RELATIONSHIP:
PRIMARY CONTINGENT
PRIMARY CONTINGENT
PRIMARY CONTINGENT
Page 2 of 2
SECTION 3: TRUST INFORMATION
BENEFIT PERCENT:
OFFICIAL NAME OF TRUST:
TAX ID NUMBER:
TRUST CONTACT:
CONTACT PHONE:
SECTION 4: REQUIRED IF NOT NAMING SPOUSE/REGISTERED PARTNER AS 100% BENEFICIARY
I acknowledge and consent to this beneficiary designation. I further understand that if Beneficiary 1 is other than myself and
has been named in Section 2 that waiving any survivor benefits to which I may become eligible to receive from StanCERA.
Spouse/Domestic
Partner Signature:
Printed Name:
Date:
Option 1: Witnessed by StanCERA Representative
Signature of spouse/registered domestic partner witnessed this
day of
, 20
.
StanCERA Representative:
Option 2: Witnessed by Notary Public – Attach separate acknowledgement certificate
THIS SECTION IS TO BE COMPLETED IF YOU ARE MARRIED/REGISTERD AND SPOUSE/PARTNER DOES
NOT CONSENT TO DESIGNATION
SECTION 5: MEMBER’S STATEMENT – NO SPOUSE/REGISTERED DOMESTIC PARTNER CONSENT
California Government Code Section 31760.3 requires notification to the current spouse/partner of the election you have made
regarding your StanCERA account. If you are married or in a registered domestic partnership, your spouse/partner’s signature
is required in Section 4 as notification of your change of beneficiary designation unless you declare under penalty of perjury, the
reason by checking one of the statements below.
I declare under penalty of perjury that my spouse/registered domestic partner signature is not included for the following reason:
□
Member is not married/registered.
□
Current spouse/registered domestic partner has no identifiable community property interest in the benefit.
□
Member does not know, and has taken all reasonable steps to determine, whereabouts of current spouse/registered domestic partner.
□
Current spouse/registered domestic partner has been advised of the application and has refused to sign the written acknowledgement.
□
Current spouse/registered domestic partner is incapable of executing the acknowledgement due to incapacitating mental or physical
conditions.
□
Member and current spouse/registered domestic partner have executed a marriage settlement agreement pursuant to Part 5
(commencing with Section 1500) of Division 4 of the Family Code, which makes the community property law inapplicable to the
marriage/partnership. (Copy of Dissolution of Marriage/Partnership accompanied by settlement must be provided.)
SECTION 3: REQUIRED SIGNATURES
In accordance with the provisions of the County Employees’ Retirement Act of 1937, I hereby revoke the nomination of
my present beneficiary and all previously named beneficiaries and hereby nominate the above as my beneficiary, to
receive any benefits payable under Article 12, Sections 31780 through 31782 of said Act in the event prior to my
retirement.
Member Signature:
Printed Name:
Date:
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ACTIVE DEFERRED BENEFICIARY CHANGE

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Completed 1 January 2021

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