Beneficiary Change Form (Option B)
(If Member Dies After Retirement)
COMMONWEALTH OF MASSACHUSETTS | PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
WEB | WWW.MASS.GOV/PERAC
Retirement
Board: Please
place your address
and phone
number here.
Choice of Beneficiary to Receive a Return of Accumulated Total Deductions
Remaining in a Member’s Annuity Account at Member’s Death
I, (Print Name) , a retired member of the
Retirement System hereby request the Board of Retirement to pay any sum referred to in G.L. c. 32, §
12(2)(b)* due at my death to the following beneficiary or beneficiaries in the proportions designated.
I understand that I may change my beneficiary designation at any time by filing a new Beneficiary Change Form
(Option B).
*The types of payments covered under G.L. c. 32, § 12(2)(b) include:
The payment of any accumulated deductions credited to a retired member's account in the annuity reserve
fund at the date of death when the member's death occurs after his/her retirement.
The amount of any uncashed checks payable to a retired member at his or her death.
Any person or entity may be a beneficiary under G.L. c. 32, § 12(2)(b). Give complete name and address of
each beneficiary below:
Proportion To Be Paid
Name SSN
Address
Name SSN
Address
Name SSN
Address
Name SSN
Address
Member’s Signature __________________________________________ Date ____________
Member’s Address
