Public Employees’ Retirement System of Mississippi
429 Mississippi Street, Jackson, MS 39201-1005 800.444.7377 601.359.3589 601.359.5262, fax www.pers.ms.gov
Beneficiary Designation
Form 1B – Revised 07/01/2016
Please print or type in black ink. Completed form should be mailed or faxed to PERS. See bottom of form for contact information.
Member/Retiree Information
First Name: _______________________________________ MI: ______ Last Name: ___________________________________ Member Retiree
Social Security No.: ____________________________ Birth Date mm/dd/ccyy: ____________________________________________ Gender: M F
Retirement Plan – Plans are governmental defined benefit plans qualified under Section 401(a) of the Internal Revenue Code. Select applicable plan.
Public Employees’ Retirement System of Mississippi (PERS) Mississippi Highway Safety Patrol Retirement System (MHSPRS)
Supplemental Legislative Retirement Plan (SLRP)
Beneficiary Information – Use additional Form 1B, Beneficiary Designation, to designate additional beneficiaries. If more than one primary beneficiary
is named, the primary beneficiaries shall share equally unless otherwise indicated. Likewise, if more than one secondary beneficiary is named, the secondary
beneficiaries shall share equally unless otherwise indicated. Total primary and secondary beneficiary percentages must equal 100 percent.
Beneficiary Name Social Security No. Birth Date Relationship Beneficiary Percentage Gender
mm/dd/ccyy P=Primary, S=Secondary
Use whole numbers
_____________________________________ ________________________ ____________ _________________ P S ________ % M F
_____________________________________ ________________________ ____________ _________________ P S ________ % M F
_____________________________________ ________________________ ____________ _________________ P S ________ % M F
_____________________________________ ________________________ ____________ _________________ P S ________ % M F
_____________________________________ ________________________ ____________ _________________ P S ________ % M F
Member/Retiree Certification – Check applicable acknowledgement then sign. If an authorized representative signs this form, attach a copy of
the durable power of attorney, conservatorship or guardianship papers, or other legal documents as proof of authority to sign this form.
Member – I acknowledge and understand that the PERS Board of Trustees is authorized to pay benefits in accordance with the statutory provisions
that govern the retirement system in which I am a member. To the extent permitted by such statutory provisions at the time of my death prior to
retirement, I hereby designate the above beneficiary(ies) to receive the payment of my accumulated contributions and any interest relating thereto. I
further acknowledge and understand that certain benefits may be required by law to be paid that may limit, partially or totally, any payment to my
designated beneficiary(ies).
Retiree – I hereby designate the above beneficiary(ies) to receive any residual amount payable by reason of my death and the death of my joint
annuitant(s), if applicable.
Member/Retiree’s Signature: ________________________________________________________________ Date mm/dd/ccyy:______________________
Employer Certification – This section must be completed by an authorized employer representative, not the member. Only complete for active members.
Employer Name: ____________________________________________________________ Employer No.: ________________ - ___________________
Employer Representative’s Name: ________________________________ Employer Representative’s Title: _____________________________________
Employer Representative’s Phone: _________________________ Fax: __________________________ E-Mail: __________________________________
Employer Representative’s Signature: _________________________________________________________ Date mm/dd/ccyy: _____________________
