OKLAHOMA TEACHERS’ RETIREMENT SYSTEM
P.O BOX 53524 - OKLAHOMA CITY, OK 73152
BENEFICIARIES DESIGNATION
Active Retired
_______________________________________________ ___________________
Name SSN# or Ret#
_______________________________________________ _____________________ _________________ __________
Address City State Zip
All information (full name, date of birth, age, relationship and address of proposed beneficiary/beneficiaries) must be completed.
SECTION 1 - PRIMARY BENEFICIARY(IES): is the sole beneficiary if living at the member’s death. If more than one beneficiary is
named in this section, the interest of all beneficiaries shall be equal. Upon the death of any designated primary beneficiary, his/her interest
shall pass to the surviving primary beneficiaries in equal share. If you have more than 2 beneficiaries, use a copy of this page.
1. I hereby designate ________________________ _________________ ___________________ ___________ ______
First Name Middle Name Last Name Date of Birth Age
________________________ ___________________________________________
Relationship Address
2. I hereby designate ________________________ _________________ ___________________ ___________ ______
First Name Middle Name Last Name Date of Birth Age
________________________ ___________________________________________
Relationship Address
as my primary beneficiary(ies) if living, or in the event of prior death of all primary beneficiaries, then payment is to be made to the
contingent beneficiaries is Section 2.
D.3B
SECTION 2 – CONTINGENT BENEFICIARY(IES): does not share in the amount due if any of the primary beneficiaries are living at
the member’s death. Payment will be made to the contingent beneficiaries if all primary beneficiaries are deceased. If more than one
contingent beneficiary is named, payment will be made in equal shares. Upon the death of a contingent beneficiary, his/her interest shall
pass to the surviving contingent beneficiaries in equal shares. If you have more than 2 contingent beneficiaries, use a copy of this page.
1. I hereby designate ________________________ _________________ ___________________ ___________ ______
First Name Middle Name Last Name Date of Birth Age
________________________ _______________________________________________________________
Relationship Address
2. I hereby designate ________________________ _________________ ___________________ ___________ ______
First Name Middle Name Last Name Date of Birth Age
________________________ _______________________________________________________________
Relationship Address
as my contingent beneficiary(ies) to receive the amount set forth in the Teachers’ Retirement Law in the event of my death. (Contingent
beneficiaries do not share in the amount due if any of the primary beneficiaries are living at my death.)
Minor Beneficiary: Under Oklahoma law, if a minor child (younger than 18 years of age) is designated as beneficiary, it will be
necessary that a guardian be appointed by the court before payment is made.
Revoking Previous Designation of Beneficiary: By this election, I hereby revoke all other former designations made by me and
expressly reserve the right to make other and further changes at any time I may elect. If there is no designated beneficiary living at the
time of my death, any amount due me shall be paid as provided by the Teachers’ Retirement Law.
_______________________________________ _______________________
Signature Date
(The signature must appear exactly as the name appears on the top of this form. Power of attorney or Guardian signature not valid unless
accompanied by court order specifically authorizing the right to change beneficiaries.)
(Rev. 03/10)
