Non-retired Members
Fax (602) 296-2368
OR scan/email to
PUBLIC SAFETY PERSONNEL RETIREMENT SYSTEM
CORRECTIONS OFFICER RETIREMENT PLAN
ELECTED OFFICIALS' RETIREMENT PLAN
3010 East Camelback Road, Suite 200
Phoenix, Arizona 85016-4416
www.psprs.com
(602) 255-5575
Form 8
09/2019
ActiveMembersGroup@psprs.com
BenefitsGroup@psprs.com
BENEFICIARY DESIGNATION FORM
Section 6109 of the Internal Revenue Code mandates disclosure of your Social Security number (SSN). We will only use your SSN to obtain account information and to
inform the Internal Revenue Service (IRS) of distributions and withholdings.
SECTION 1 – PRINT Member Information
SSN
SYSID (if known)
Non-retired Retired DROP
For DROP payment, complete DROP
Beneficiary Designation Form (P8DROP)
Date of Birth (MM/DD/YYYY) E-mail Address (We will also update the “Members Only” in http://www.psprs.com)
Last Name
First Name, Middle Initial
New Address?
Yes No
Mailing Address - City, State and ZIP +4
County
Home Phone #
( )
Cell #
( )
Work #
( )
SECTION 2 – IMPORTANT Beneficiary Information
Pursuant to statute
, an AUTOMATIC survivor benefit pays your:
o
Eligible Spouse. Proof of
recorded
marriage license/certificate will be required. Failure to provide acceptable documentation may affect the
surviving spouse benefits. If you are currently receiving a monthly benefit, statute requires two consecutive years of marriage.
o
Eligible Child(ren) that is(are) unmarried, under the age of 18, and/or attending full-time school between the ages of 18 to 23, plus disabled
child(ren) if disability occurred before the age of 23 and who is(are) a dependent of the member.
If no eligible spouse or eligible child(ren), the balance of any applicable contributions, if any, will be paid to the named beneficiary(ies) indicated below.
To update your beneficiary for your Deferred Retirement Option Plan (DROP) payment, complete a DROP Beneficiary Designation Form (P8DROP).
Note: Divorce automatically terminates your ex-spouse for a surviving spouse pension; however, to maintain your ex-spouse as a beneficiary of any
remaining contributions on account, you must complete a new Beneficiary Designation Form after the date of divorce.
Primary Beneficiary Name(s)
SSN
Name of Beneficiary (Last, First, Middle)
Relationship (check one)
Spouse Child Disabled Child
Parent Sibling Other
Birth Date (MM/DD/YYYY) Address (City, State, ZIP +4) Telephone #
( )
Check ONE Primary OR Secondary Beneficiary (If not checked, the following beneficiary is a Primary Beneficiary)
SSN
Name of Beneficiary (Last, First, Middle)
Relationship (check one)
Spouse Child Disabled Child
Parent Sibling Other
Birth Date (MM/DD/YYYY) Address (City, State, ZIP +4) Telephone #
( )
Check ONE Primary OR Secondary Beneficiary (If not checked, the following beneficiary is a Primary Beneficiary)
SSN Name of Beneficiary (Last, First, Middle)
Relationship (check one)
Spouse Child Disabled Child
Parent Sibling Other
Birth Date (MM/DD/YYYY) Address (City, State, ZIP +4) Telephone #
( )
SECTION 3 – REQUIRED Signatures (electronic signature cannot be accepted)
PRINT Witness Name (cannot be a beneficiary listed above) Witness Signature Date
Member’s Signature
Date
If signing as a POA or Guardian, if you have not already done so, provide our office with a copy of your appointment papers.
For additional beneficiaries, copy and attach this form. Check this box if there is an additional form attached.
Retired/DROP Members
Fax (602) 296-2369
OR email to
