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Ers Beneficiary Designation Rs5127 (Mohawk Valley Community College)

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Designation of Beneficiary
With Contingent Beneficiaries
RS 5127
(Rev. 9/14)
Office of the New York State Comptroller
New York State and Local Retirement System
Employees’ Retirement System
Police and Fire Retirement System
110 State Street, Albany, New York 12244-0001
For Office Use Only
Receipt Date
_____________________________ _______________________
__________________________________________________ ___________________________________________
________________________________________________________________________________________________________
_______________________________________ ____________________________________________
________________________________________ ___________________________________________
THIS FORM MUST BE SIGNED, NOTARIZED AND FILED WITH THE
RETIREMENT SYSTEM PRIOR TO YOUR DEATH TO BE EFFECTIVE.
IMPORTANT INFORMATION REGARDING THIS FORM
• If you find this form is not suited to the type of designation you prefer
please advise the Retirement System. In the meantime, for your
protection and the protection of your beneficiary(ies), you should
make an interim designation using this form. If you wish to designate
more beneficiaries than this form allows or to designate a Trust,
Guardianship or payment under the Uniform Transfers to Minors
Act please contact the Retirement System for the appropriate form.
• Attachments to your beneficiary form are unacceptable.
• New beneficiary forms filed will supersede any previous designation.
Therefore, if you want to add or delete a beneficiary, for example a
new child, you must include on the new form all beneficiaries you
wish to designate.
• The same person or persons cannot be designated as both primary
and contingent beneficiaries. We make payment to a contingent
beneficiary(ies) only if all primary beneficiary(ies) die before you do.
• If you wish to have these benefits distributed through your estate,
you should name “my estate” as beneficiary. Your estate can be
named as either primary or contingent beneficiary. However, if you
name your estate as primary beneficiary, you may not name any
contingent beneficiary.
• This form is for designating beneficiaries to receive your ordinary
death or post retirement death benefit. You may not designate
beneficiaries to receive accidental death benefits. The beneficiaries
entitled to receive accidental death benefits are mandated by statute.
Make sure that you:
• Complete all requested information.
• Sign and date the form.
• Have the form notarized, making sure the notary has entered
the date his or her commission expires.
• Mail your completed form to:
New York State and Local Retirement System
Member & Employer Services
Registration – Mail Drop 5-6
110 State Street
Albany, NY 12244-0001
PERSONAL PRIVACY PROTECTION LAW
In accordance with the Personal Privacy Protection Law you are hereby advised that
pursuant to the Retirement and Social Security Law, the Retirement System is required to
maintain records. The records are necessary to determine eligibility for and to calculate
benefits. Failure to provide information may result in the System’s inability to pay
benefits the way you prefer.The System may provide certain information to participating
employers. The official responsible for maintaining these records is the Director of
Member & Employer Services, New York State and Local Retirement Systems, Albany, NY
12244. For questions concerning this form, please call 1-866-805-0990 or 518-474-7736.
Member/Pensioner Information
Please PRINT clearly, using only blue or black ink.
Registration/Retirement Number: Last 4 Digits of Social Security Number*
*
SOCIAL SECURITY DISCLOSURE REQUIREMENT
In accordance with the Federal Privacy Act of 1974, you are hereby advised that
disclosure of the Social Security Account Number is mandatory pursuant to sections
11, 31, 34 and 334 of the Retirement and Social Security Law. The number will be used
in identifying retirement records and in the administration of the Retirement System.
Name: Former Name:
Home Address:
City, State, Zip Code: Date of Birth:
Telephone Number: Email Address:
Employed By: Employer Address:
Please go to the reverse side of this form to designate beneficiaries, sign and date the form, and
have the form notarized.
RS 5127 (front)
Do not alter this form or make stipulations. The use of correction fluid or other alterations on this form will render the designation invalid.
To the Comptroller of the State of New York.
Designation of Primary Beneficiary(ies). I hereby name the following beneficiary(ies) to receive any ordinary death or post retirement death benefit, payable
on my behalf. If I have named more than one beneficiary, it is my intention that those living at the time of my death should share equally any benefit payable. I
reserve the right to change this designation at any time.
Name Male Female
Address
Relationship
Birth Date
Telephone Number
Name Male Female
Address
Relationship
Birth Date
Telephone Number
Name Male Female
Address
Relationship
Birth Date
Telephone Number
Name Male Female
Address
Relationship
Birth Date
Telephone Number
Name Male Female
Address
Relationship
Birth Date
Telephone Number
Name Male Female
Address
Relationship
Birth Date
Telephone Number
Designation of Contingent Beneficiary(ies). If all of the designated primary beneficiaries die before I do, any ordinary death or post retirement death benefit
payable on my behalf shall be paid to the following. If I have named more than one beneficiary, it is my intention that those living at the time of my death should
share equally any benefit payable. If I out-live all of these contingent beneficiaries, any benefit payable should be paid to my estate. I reserve the right to change
this designation at any time.
Name Male Female
Address
Relationship
Birth Date
Telephone Number
Name Male Female
Address
Relationship
Birth Date
Telephone Number
Name Male Female
Address
Relationship
Birth Date
Telephone Number
Name Male Female
Address
Relationship
Birth Date
Telephone Number
This form must be signed, dated and notarized in order to be valid
Member/Pensioner Signature Date
Acknowledgement To Be Completed by a Notary Public
State of _____________________________________________ County of ____________________________________________
On the ______ day of _________________ in the year _________ before me, the undersigned, personally appeared ____________________________, personally
known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged
to me that he/she/they executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon
behalf of which the individual(s) acted, executed the instrument.
NOTARY PUBLIC (Please sign and affix stamp)
RS 5127 (Rev. 9/14)
reverse
Notary Public Stamp
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Ers Beneficiary Designation Rs5127 (Mohawk Valley Community College)

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Completed 23 July 2020

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