The Affidavit To be Filed with the Retirement Board by Spouse Seeking Member Survivor Allowance
provides important information to allow a retirement board to determine a spouse's eligibility
for and amount of survivor benefits.
l The spouse must file a copy of his/her marriage certificate with this affidavit.
Introduction
Affidavit to be Filed with the Retirement Board by Spouse
Seeking Member Survivor Benefits
Form Last Revised: October, 2001
COMMONWEALTH OF MASSACHUSETTS | PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
WEB | WWW.MASS.GOV/PERAC
Affidavit to be Filed with the Retirement Board by Spouse
Seeking Member Survivor Benefits
Form Last Revised: October, 2001
To the Retirement Board:
Name of Deceased Member
In order that the board may properly determine a survivor’s right to benefits, if any, that accrue from a deceased
member’s membership in a Massachusetts public retirement system under G.L. c. 32, §§ 1-28, the following
information is respectfully submitted.
Please check “yes” or “no” when applicable.
l) Were you married to and living with your spouse on , the date of his/her death?
Yes No
If no, please attach a statement providing the details about why you were living apart. You must establish the
fact that any separation was for a justifiable cause other than your desertion or moral turpitude.
2) Do you have any children who are under age eighteen? Yes No
If yes, please list their names, dates of birth, and include a copy of each child’s birth certificate.
NAME DATE OF BIRTH SOCIAL SECURITY #
3) Do you have any children who are over eighteen and mentally or
physically incapacitated from earning? Yes No
If yes, please list their names, dates of birth, and include a copy of each child’s birth certificate and proof of
their incapacity.
NAME DATE OF BIRTH SOCIAL SECURITY #
COMMONWEALTH OF MASSACHUSETTS | PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
WEB | WWW.MASS.GOV/PERAC
Retirement
Board: Please
place your address
and phone
number here.
4
4) Do you have any children who are over age eighteen and under age
twenty-two who are full time students? Yes No
If yes, please list their names, dates of birth and include a copy of each child’s birth certificates and proof of
student status.
NAME DATE OF BIRTH SOCIAL SECURITY #
5) Was the above named member a Veteran? Yes No
If yes, a copy of the military form DD214 must be filed.
6) What is the date of your marriage to the above named member?
7) What is your date of birth?
I sign this form under the pains and penalties of perjury. I affirm that the information presented in this form is
correct, complete and accurately presented. I understand that giving false or incomplete information may sub-
ject me to the loss of my benefits as well as civil and criminal penalties.
Signature of Spouse (Applicant) ____________________________________ Date ___________
Print Name Social Securiity # Phone #
Street and Number City/Town State Zip
Affidavit to be Filed with the Retirement Board by Spouse Seeking Member Survivor Benefits 2
Member’s Last Name First M.I. Social Security #
CLEAR
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