RETIREMENT BOARD | EMPLOYEE RETIREMENT SYSTEM
Providence City Hall | 25 Dorrance Street, Room 409, Providence, Rhode Island 02903
401 421 7740 ph | 401 453 6175 fax
www.providenceri.com
DESIGNATION OF BENEFICIARY
I, ___________________________________, a member of the Employee Retirement
(member name)
System of the City of Providence, hereby designate __________________________ who is my
(name of beneficiary)
___________________ and who was born on __________________, having Social Security
(relationship to employee) (beneficiary date of birth)
Number _________________ and whose address is __________________________________
(SSN of beneficiary) (address of beneficiary)
as the beneficiary to whom I authorize to receive the total amount of accumulated contributions
and/or interest, standing to my credit in the Employee Retirement System, upon my death.
Should I survive said beneficiary, I direct that the amount of such accumulated
contributions and/or interest shall be paid to my legal representative, or to such other
beneficiary as I shall hereafter nominate prior to the date of my retirement.
_____________________________________________
Signature of Member of Employee Retirement System
ACKNOWLEDGMENT
County of _______________,
State of _________________:
On this ____ day of ______________________, 20___ the member named above
_________________________________ known to me to be the person described in and who
executed the forgoing instrument acknowledged that __he executed the same and being duly
sworn by me made oath that the statements made herein are true.
Notary Signature ________________________ Commission Expiration ____________
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