Fillable DESIGNATION OF BENEFICIARY ALTERNATE BENEFIT PROGRAM (ABP) / (Hudson County Community College)

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DESIGNATION OF BENEFICIARY ALTERNATE BENEFIT PROGRAM (ABP) / (Hudson County Community College)

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BROWSE HUDSON COUNTY COMMUNITY COLLEGE FORMS

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EB-0791-0519
State of New Jersey • Department of the Treasury
DIVISION OF PENSIONS & BENEFITS — BENEFICIARY SERVICES
P.O. Box 295, Trenton, NJ 08625-0295
DESIGNATION OF BENEFICIARY —
ALTERNATE BENEFIT PROGRAM (ABP) /
DEFINED CONTRIBUTION RETIREMENT PROGRAM (DCRP)
ABOUT THE DESIGNATION OF BENEFICIARY FORM
This form will replace all prior designations of beneciary(ies). For more information about your
retirement contributions contact your investment carrier.
The Designation of Beneficiary form allows a member of a New Jersey Alternate Benet Program
(ABP) or Dened Contribution Retirement Program (DCRP) to nominate a beneciary, or bene-
ciaries, for benets payable upon the death of that member. This form applies to the group life
insurance for active and retired members of the ABP or DCRP.
GROUP LIFE INSURANCE
This designation is for any group life insurance benet payable at the time of your death. Group
life insurance does not apply to retirees with less than 10 years of service credit, or members who
enrolled at age 60 or older and failed to prove insurability.
PRIMARY AND CONTINGENT BENEFICIARIES
Please be sure to designate both primary and contingent beneciaries. In the event of your death,
the primary beneciary(ies) will receive any death benets that are payable. The contingent bene-
ciary(ies) will receive death benets only if all primary beneciaries have predeceased you.
Unless otherwise stated, all beneciaries will share and share alike. If no primary or contingent
beneciaries survive you, all death benets will be paid to your estate.
You may nominate any of the following as your primary or contingent beneciary:
• A person or persons;
• An institution, charity, or corporation; or
• Your estate. Upon your death a court ordered surrogate certicate will be required.
If you choose a distribution of benets other than the standard share and share alike, or if you
are naming a minor, using a trust agreement, acting as a power of attorney for the member, or
nominating a civil union partner or domestic partner, please refer to the Beneficiary Designation
Fact Sheet before completing this form. You may obtain this fact sheet by visiting our website at:
www.nj.gov/treasur y/pensions
ORIGINAL FORM MUST BE SUBMITTED IN BLUE INK. ALL REQUESTED INFORMATION MUST BE PROVIDED.
PLEASE READ AND FOLLOW THE INSTRUCTIONS BEFORE COMPLETING THIS FORM.
Contribution Program: (Check one) o ABP o DCRP
Employment Status: (Check one) o Active o Retired
Print Your Full Name: ________________________________________________________________________________________
Birth Date: _________/ ________ / _________ Social Security Number: _________________________________________
Location Name: __________________________________________________________
Active and Retired Group Life Insurance
Primary Beneficiary(ies)
Beneficiary Name Relationship Social Security Number Birth Date
1. ____________________________________ ____________________________ __________________ ____________
Address __________________________________________________________________________________________________
2. ____________________________________ ____________________________ __________________ ____________
Address __________________________________________________________________________________________________
3. ____________________________________ ____________________________ __________________ ____________
Address __________________________________________________________________________________________________
Contingent Beneficiary(ies) - If primary beneficiary is not living at my death, payment is to be made to:
Beneficiary Name Relationship Social Security Number Birth Date
1. ____________________________________ ____________________________ __________________ ____________
Address __________________________________________________________________________________________________
2. ____________________________________ ____________________________ __________________ ____________
Address __________________________________________________________________________________________________
3. ____________________________________ ____________________________ __________________ ____________
Address __________________________________________________________________________________________________
_____________________________________________________________________________ ___________________________
Member Signature Date
Mailing Address _____________________________________________________________________________________________
Daytime Telephone Number (_____) _____________________________
EB-0791-0519
State of New Jersey • Department of the Treasury
DIVISION OF PENSIONS & BENEFITS — BENEFICIARY SERVICES
P.O. Box 295, Trenton, NJ 08625-0295
DESIGNATION OF BENEFICIARY —
ALTERNATE BENEFIT PROGRAM (ABP) /
DEFINED CONTRIBUTION RETIREMENT PROGRAM (DCRP)
click to sign
signature
click to edit
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 beneciary(ies) and contingent
beneciary(ies). If this section is not completed, this benet 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 beneciary 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
Security number.
Submit completed form to: New Jersey Division of Pensions & Benefits
ABP/DCRP
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
pensions.nj@treas.nj.gov 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 beneciary, be certain the
proper name is given, e.g., Mary J. Jones, not Mrs. John R. Jones.
Do use specic names. The phrase “my children” or “my grandchildren” will not be accepted. You must list each child
using his or her specic 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 beneciary 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 beneciary’s address. A signed letter notifying us of your bene-
ciary’s address change will sufce. Your letter will be added to your le so your beneciary 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 beneciary 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 benets. For any designation not naming
a specic person or a share and share alike distribution, please refer to the Beneficiary Designation Fact Sheet.
EB-0791-0519
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DESIGNATION OF BENEFICIARY ALTERNATE BENEFIT PROGRAM (ABP) (Hudson County Community College)

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Completed 29 January 2021

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