Fillable CMERS Beneficiary Form OmniForm Form

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CMERS Beneficiary Form OmniForm Form

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The CMERS Beneficiary Form OmniForm Form form is 1 page long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for City of Bridgeport

BROWSE CITY OF BRIDGEPORT (CT) FORMS

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FEMALE
SINGLE
MARRIED
City of Bridgeport (015 )
YES
NO
45 Lyon Terrace, Bridgeport, CT 06604
MUNICIPAL EMPLOYEE RETIREMENT SYSTEM
POLICE & FIREMAN FUND
N/A
Part-time
MUNICIPAL EMPLOYEE RETIREMENT SYSTEM - DESIGNATION OF BENEFICIARY
CO-931 MERS 9/2015
STATE OF CONNECTICUT
OFFICE OF THE STATE COMPTROLLER
RETIREMENT SERVICES DIVISION
CHECK TYPES OF ACTIONS BEING SUBMITTED ON THIS FORM - THEN CONSULT APPLICABLE INSTRUCTIONS
NEW
EMPLOYEE
RE-EMPLOYED,
MULTIPLE EMPLOYMENT
EMPLOYEE NAME
AND/OR ADDRESS
CHANGE
CHANGE IN
BENEFICIARY(IES) NAME
AND/OR ADDRESS
I. EMPLOYEE INFORMATION
EMPLOYEE NAME (Last)
First Name
M.I.
SOC. SEC. NUMBER
DATE OF EMPLOYMENT
DATE OF BIRTH
GENDER
EMPLOYEE'S HOME ADDRESS (Street No., Name, City, State, Zip Code)
MARITAL STATUS
DATE OF MARRIAGE
NAME OF SPOUSE
EMPLOYING TOWN
TOWN ADDRESS
IS THIS EMPLOYEE CURRENTLY
EMPLOYED BY ANOTHER TOWN?
IF YES, PROVIDE THE TOWN NAME
II. RETIREMENT INFORMATION
RETIREMENT SYSTEM
MEMBER ID
EMPLOYMENT STATUS
Full-time
III. BENEFICIARY INFORMATION
IF THERE ARE MORE THAN (4) BENEFICIARIES DESIGNATED, CHECK THE BOX TO THE
RIGHT AND ATTACH AN ADDITIONAL CO-931 FORM LISTING ADDITIONAL BENEFICIARIES
NAME OF BENEFICIARY
SOCIAL SECURITY NO.
NAME OF BENEFICIARY
CONTINGENT
Last Name
First Name
M.I.
Last Name
First Name
M.I.
SOCIAL SECURITY NO.
ADDRESS (Street No., Name)
RELATIONSHIP
ADDRESS (Street No., Name)
RELATIONSHIP
(City, State, Zip Code)
PERCENT
DATE OF BIRTH
(City, State, Zip Code)
PERCENT
DATE OF BIRTH
NAME OF BENEFICIARY
CONTINGENT
NAME OF BENEFICIARY
CONTINGENT
Last Name
First Name
M.I.
SOCIAL SECURITY NO.
Last Name
First Name
M.I.
SOCIAL SECURITY NO.
ADDRESS (Street No., Name)
RELATIONSHIP
ADDRESS (Street No., Name)
RELATIONSHIP
(City, State, Zip Code)
PERCENT
DATE OF BIRTH
(City, State, Zip Code)
PERCENT
DATE OF BIRTH
IV. MEMBER'S STATEMENT
I understand the provisions of the retirement plan and that, if applicable, I will be required to make contributions based upon my retirement plan designation. Further, I hereby revoke
all previous appointments of beneficiaries made by me, if any, and designate the person(s) named above as beneficiary(ies) to receive upon my death any and all sums due from the
Municipal Employee Retirement System. This designation shall remain in effect unless I subsequently change it by written notice to the Retirement Services Division.
EMPLOYEE'S SIGNATURE
DATE
AUTHORIZED TOWN SIGNATURE & TITLE
PHONE
DATE
203-576-7105
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CMERS Beneficiary Form OmniForm Form

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Completed 11 July 2020

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