INSTRUCTIONS FOR COMPLETING THE DESIGNATION OF BENEFICIARY FORM
Indicate Your Contribution Program — Check the appropriate box of the contribution program of which
you are a member.
Indicate Your Employment Status — Check the box to indicate if you are an active employee or retired member.
Member Information — Print your full name, date of birth, and full Social Security number.
Location Name — Print the name of your active or retired employer location.
Nominate Your Group Life Insurance Beneﬁciary — Print the name of your primary beneciary(ies) and contingent
beneciary(ies). If this section is not completed, this benet will automatically default to your estate.
All members must complete the following – Make sure to sign, date, and provide your address and daytime tele-
phone number on the form. On any additional sheets used to specify beneciary information, please be sure to include
your signature and date on the sheet, and print your name, address, daytime telephone number, and your full Social
Submit completed form to: New Jersey Division of Pensions & Beneﬁts
P.O. Box 295
Trenton, NJ 08625-0295
If you have any questions on how to complete your Designation of Beneﬁciary form, send an email to
email@example.com or visit www.nj.gov/treasury/pensions
DOS AND DON’TS OF BENEFICIARY DESIGNATION
Do complete and submit this original form using only blue ink. Completing this form in pencil or any ink color other than
blue makes the form unacceptable. Copies of the Designation of Beneﬁciary form are not accepted.
Do use proper names. Nicknames are not acceptable. When naming a married female as beneciary, be certain the
proper name is given, e.g., Mary J. Jones, not Mrs. John R. Jones.
Do use specic names. The phrase “my children” or “my grandchildren” will not be accepted. You must list each child
using his or her specic name.
Do make a copy of your completed Designation of Beneﬁciary form for your records before submitting the original and
periodically review it to make sure all beneciary information is correct. It is especially important to update this informa-
tion after a life event such as a birth, marriage, divorce, or death.
Don’t use a Designation of Beneﬁciary form to update a beneciary’s address. A signed letter notifying us of your bene-
ciary’s address change will sufce. Your letter will be added to your le so your beneciary information remains current.
Don’t use white out or cross out names to make changes in designation. This makes the form unacceptable and a new
form will be mailed to you.
Don’t name the same person or persons in both the primary and contingent beneciary sections. This makes the form
unacceptable and a new form will be mailed to you.
Before submitting the Designation of Beneﬁciary form, be sure to complete all the items indicated above. Failure to
complete this form totally and accurately may jeopardize the payment of your benets. For any designation not naming
a specic person or a share and share alike distribution, please refer to the Beneﬁciary Designation Fact Sheet.