Designation of Retiring Members' Beneciaries
Your Information
Print or type all personal
information below.
___________________________________ _______________________ ____________
Last Name First Name Middle Initial
Beneciary
Designation
*Note: This form is to be
used by members who
have submitted their
application for retirement
but have not received
their rst retirement
check. **The beneciary
information on this form
supersedes beneciary
information previously
submitted on a member's
retirement application.
Please designate your
primary and secondary
beneciaries.
The total percentage for
primary beneciaries
should equal 100%.
The total percentage for
secondary beneciaries
should equal 100%. For
example, if you have 3
primary beneciaries, you
need to make sure that the
percentages allotted equal
100% (e.g., 40%, 30%,
30%).
Social Security Number
Your Signature
Please sign and date
verifying the information
provided above is accurate.
MB-1 (1116)
__________________________________________________ __________________
Signature Date
To Be Completed by Member -- please print clearly
Teachers
Retirement
System of
Georgia
Two Northside 75 Suite 100 Atlanta, GA 30318 (404) 352-6500 (800) 352-0650 fax (404) 352-4885 www.trsga.com
This form is only for members who have submitted their application for retirement.
1.
Name of Beneciary Date of Birth Sex (M or F) Relationship to Me
Address City State Zip Code
Soc. Sec. No. Percentage of available benets to be paid %
2.
Name of Beneciary Date of Birth Sex (M or F) Relationship to Me
Address City State Zip Code
Soc. Sec. No. Percentage of available benets to be paid %
3.
Name of Beneciary Date of Birth Sex (M or F) Relationship to Me
Address City State Zip Code
Soc. Sec. No. Percentage of available benets to be paid %
4.
Name of Beneciary Date of Birth Sex (M or F) Relationship to Me
Address City State Zip Code
Soc. Sec. No. Percentage of available benets to be paid %
5.
Name of Beneciary Date of Birth Sex (M or F) Relationship to Me
Address City State Zip Code
Soc. Sec. No. Percentage of available benets to be paid %
PRIMARY BENEFICIARIES
1.
Name of Beneciary Date of Birth Sex (M or F) Relationship to Me
Address City State Zip Code
Soc. Sec. No. Percentage of available benets to be paid %
2.
Name of Beneciary Date of Birth Sex (M or F) Relationship to Me
Address City State Zip Code
Soc. Sec. No. Percentage of available benets to be paid %
3.
Name of Beneciary Date of Birth Sex (M or F) Relationship to Me
Address City State Zip Code
Soc. Sec. No. Percentage of available benets to be paid %
SECONDARY BENEFICIARIES
click to sign
signature
click to edit
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