Fillable Beneficiary (Nebraska)

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Beneficiary (Nebraska)

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The Beneficiary (Nebraska) form is 2 pages long and contains:

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  • 6 check-boxes
  • 160 other fields

Country of origin: US
File type: PDF

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NPERS1300
Rev. 03/2018
Page 1 of _____
BAR CODE
Last First Middle Maiden
Name
Date of Birth - -
Plan Type
(check all that apply)
Social Security Number - -
Email Address
School
State
County
Judges
Patrol
DCP
Address City State Zip
Home Phone
Work Phone
Employer
Beneficiary Designation Form
READ CAREFULLY BEFORE COMPLETING: Benefits will be paid to your survivors exactly as you provide on this form. This form
supersedes prior beneficiary designation forms. If you name a trust or other legal entity as your beneficiary, include the name of both the
trust and the trustee. Submit the original document only; photocopies and faxes will not be accepted. If you wish to designate more
than five beneficiaries in either the Primary or Contingent category, you must attach a supplemental form(s) and indicate the number of
additional pages here. _______
PRIMARY BENEFICIARY(IES): I designate the following person(s) to be my Primary Beneficiary(ies) for the Retirement Plan noted above. All
Primary Beneficiaries designated will share equally in the benefit unless I have included a percentage (%) amount on the line
following the date of birth below. (The shares of all Primary Beneficiaries must total 100%.) PLEASE PRINT.
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
CONTINGENT BENEFICIARY(IES): I designate the following person(s) to be my Contingent Beneficiary(ies) for the Retirement Plan noted
above. I understand my Contingent Beneficiary(ies) will receive a share of my benefit if all Primary Beneficiaries pre-decease me or refuse their
shares of the benefit. All Contingent Beneficiaries designated will share equally in the benefit unless I have included a per
centage (%) amount on
the line following the date of birth below. (The shares of all Contingent Beneficiaries must total 100%.) PLEASE PRINT.
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
SIGNATURE OF MEMBER________________________________________________________________________________ Date _____________________
I hereby certify that the above member, whose identity I have established to my own
satisfaction, freely and voluntarily signed this beneficiary designation form in my presence.
State of ______________________________
County of_____________________________
Subscribed and sworn before me this ______ day of _______________________, ____________.
NOTARY PUBLIC SIGNATURE _____________________________________________________ My commission expires: __________________.
}
STAMP HERE
M / F
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NPERS1300
Rev. 03/2018
Page_____ of _____
BAR CODE
Beneficiary Designation Supplemental Form
IMPORTANT: This form is to be used as a supplement to the Beneficiary Designation Form only if you wish to designate more than
five Primary or Contingent Beneficiaries. You may use as many Supplemental forms as needed. This form will NOT be accepted
without the original, notarized Beneficiary Designation Form.
NAME ________________________________________________________________________________________________________________________________
SOCIAL SECURITY NUMBER ________________-_____________-________________
PRIMARY BENEFICIARY(IES) (continued):
Fill in a percentage amount (%), for all persons designated below (the shares of all primary beneficiaries must total 100%,
including those listed on page 1). If all beneficiaries are to share equally, no percentage needs to be listed. PLEASE PRINT.
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
CONTINGENT BENEFICIARY(IES) (continued):
Fill in a percentage amount (%), for all persons designated below (the shares of all contingent beneficiaries must total 100%,
including those listed on page 1). If all beneficiaries are to share equally, no percentage needs to be listed. PLEASE PRINT.
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary Spouse/Child/Other Gender Social Security Number Date of Birth %
SIGNATURE OF MEMBER________________________________________________________________________________ Date _____________________.
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M / F
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0.00
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Beneficiary (Nebraska)

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Completed 21 July 2020

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