FST-12 Florida Retirement System Pension Plan
Effective 07/16 Retired Member and DROP Participant Beneficiary Designation Form
Survivor Benefits PO Box 9000 Tallahassee, FL 32315-9000
Local Phone: 850-907-6500 Toll Free: 844-377-1888 Fax: 850-410-2010
Member SSN: _Member Name: ___________________________________ _________________________
Please list (type or print) your beneficiaries’ information below. To designate more than two primary or
contingent beneficiaries, use additional copies of this form as needed. If additional forms are required, the total
percentage between all forms must equal 100 percent. Write the sequence of multiple pages at the top of each
form. For example: Page 1 of 2.
1. Primary Beneficiary(s) - Indicate percentages if naming more than one primary beneficiary. Percentages
should total 100 percent. After the death of all primary beneficiaries, any remaining benefits are paid to the
contingent beneficiary(s).
A. % ________ ___________________ _________________________________________ ______ ______
Name of Primary Birthdate Gender Relationship Percentage
__ ________________________________ ___________________________________________ _______
SSN of Primary Primary Address Primary Phone
B. % ________ ___________________ _________________________________________ ______ ______
Name of Primary Birthdate Gender Relationship Percentage
__ ________________________________ ___________________________________________ _______
SSN of Primary Primary Address Primary Phone
2. Contingent Beneficiary(s) - Indicate percentages if naming more than one contingent beneficiary.
Percentages should total 100 percent. After the death of all primary beneficiaries and contingent
beneficiaries, any remaining benefits are paid to the last beneficiary’s estate.
A. ________ % ___________________ _________________________________________ ______ ______
Name of Contingent Birthdate Gender Relationship Percentage
___ ________________________________ __________________________________________ ________
SSN of Contingent Contingent Address Contingent Phone
B. ________ % ___________________ _________________________________________ ______ ______
Name of Contingent Birthdate Gender Relationship Percentage
___ ________________________________ __________________________________________ ________
SSN of Contingent Contingent Address Contingent Phone
Member Signature (sign in the presence of a Notary) ______________________________________________________
Notary:
The above named person who has , County ofState of _____________________ _________________
and who is 20 _day of _sworn to and subscribed before me this _______ _______________________ ____
identification. or produced personally known ________ _______________________________________
_______________________________
Signature of Notary Public
Rule 60S-4.011, F.A.C ________________________________________________________________________________
Page 1 of 1 Print, Type or Stamp Commissioned Name of Notary Public
