Death Benefit Claimant Form
PART A. CLAIMANT INFORMATION
A1. Name
A3. Address Line 1
A4. Address Line 2
You must review, sign, and date this form in front of a registered notary.
Richmond Retirement System | 730 E. Broad Street, Suite 900, Richmond, Virginia, 23219 | Tel: (804) 646 - 5958 | Fax: (804) 646-5299 | www.richmondgov.com/retirement
PART B. DECEASED MEMBER INFORMATION
PART C. CERTIFICATION
Form revised January 2016
A5. Phone Number
A2. Date of Birth
A6. Email Address
A7. You are claiming this benefit: __ as a named beneficiary __ on behalf of an institution or estate.
If on behalf of institution or estate (i) attach legal documentation outlining your authority and (ii) provide EIN in Box A8.
A9. Your relationship to the deceased: __ spouse __ child __ friend __other:___________________
B1. Name
B2. Social Security #
B3. Date of Death
B4. Confirm that an original CERTIFICATE OF DEATH or original VERIFICATION OF DEATH is attached: __
By signing the below I certify that the information provided on this form is true, complete, and accurate to the best of my
knowledge. I also certify that I am legally entitled to this benefit.
The individual whose name is signed above appeared before me, acknowledged the signature to be his/hers, and having
been sworn by me, made an oath that the statements are true.
C3. Notary Signature
C7. City, State
C9. Notary Registration #
C6. Notary Printed Name
C8. Commission Expires
C4. Date (must match Box C2)
C1. Claimant Signature C2. Date (must match Box C4)
C5. Seal / Stamp:
RRS USE ONLY
DIRECTIONS
Please fill out your form, typed
or printed in ink, and submit to:
730 E. Broad Street, Suite 900
Richmond, VA 23219
All forms are processed on the
15th of the month, and checks
are mailed the last business day
of the month.
A8. Social Security #
1.City Code Sec:
___22-296
___22-297
2.Legacy #
#____________
3.Oracle #
#____________
4.Date of Birth
___ / ___ / ___
5.Death Benefit,
Less Overpayments
$____________
6. Beneficiary #
#____ of ____
7.Payment Amount
$____________
8.Payment Date
___ / ___ / ___
9.Reviewer #1
10.Reviewer #2
11.Notes:
