The Beneficiary Selection Form allows a member to select an eligible beneficiary to receive an
allowance if the member dies before retirement and to select a beneficiary(ies) to receive pay-
ment of accumulated deductions and other payments due to a member if the member dies
before retirement. Keep in mind:
l Only certain of your relatives qualify as an eligible beneficiary for benefits under G.L. c.
32, § 12(2)(d), but any person or entity can be selected as a beneficiary(ies) for a return
of your accumulated total deductions.
l Your selection on this form may be superseded by an eligible spouse under the provisions
of G.L. c. 32, § 12(2)(d) if you die before retirement.
l This form becomes void upon your retirement.
l If you divorce or your personal situation changes, you may wish to file a new form with
your retirement board.
Introduction
Beneficiary Selection Form
(If Member Dies Before Retirement)
Form Last Revised: October, 2001
COMMONWEALTH OF MASSACHUSETTS | PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
WEB | WWW.MASS.GOV/PERAC
Beneficiary Selection Form
(If Member Dies Before Retirement)
Form Last Revised: October, 2001
COMMONWEALTH OF MASSACHUSETTS | PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
WEB | WWW.MA.US/PERAC
Retirement
Board: Please
place your address
and phone
number here.
4
Choice of Beneficiary to Receive a Return of Accumulated Total Deductions
at Member’s Death
I, (Print Name) , a member of the
Retirement System hereby request the Board of Retirement to pay any sum referred to in G.L. c. 32, § 11(2)*
due at my death to the following beneficiary or beneficiaries in the proportions designated.
My selection may be superseded by a selection under G.L. c. 32, § 12(2)(d) if I die leaving an eligible spouse
who elects to receive a monthly benefit.
I understand that I may change my beneficiary designation at any time prior to my retirement and that upon
my retirement, this form becomes void.
*The types of payments covered under G.L. c. 32, § 11(2) include:
l The payment of the accumulated deductions credited to a member's account in the annuity savings fund at
the date of death when the member's death occurs prior to his/her retirement.
l The amount of any uncashed checks payable to a member at his or her death.
l Any person or entity may be a beneficiary under G.L. c. 32, § 11(2). Give complete name and address of
each beneficiary below:
Proportion To Be Paid
Name SSN
Address
Name SSN
Address
Name SSN
Address
Name SSN
Address
Member’s Signature __________________________________________ Date ____________
Member’s Address
Beneficiary Selection Form 2
Member’s Last Name First M.I. Social Security #
Choice of Option (D) Beneficiary
I, (Print Name) , a member of the
Retirement System, hereby nominate the beneficiary * listed below, under the provisions of G.L. c. 32, § 12(2)(d)
to receive from the retirement system a benefit equal to the Option (C) retirement allowance which would
otherwise have been payable to me in the event that I die before being retired.
I understand that I may change my beneficiary designation at any time prior to my retirement and that upon
my retirement this form becomes void.
I understand that this choice of Option D Beneficiary can be superceded if, at my death, I leave a spouse to
whom I have been married for over one year and with whom I am living on the date of my death, or if living
apart, for justifiable cause as determined by the Retirement Board.
Beneficiary
Name of Eligible Beneficiary Beneficiary’s Relationship to Member
Beneficiary’s Date of Birth (Attach birth record) Beneficiary’s Social Security #
Member
Member’s Signature __________________________________________ Date ___________
Member’s Street Address Member’s Social Security #
City/Town State Zip
To Be Completed by Witness of Choice of Option D Beneficiary
Witness’ Signature __________________________________________ Date ___________
Witness’ Name (Print)
* An eligible beneficiary is defined under G.L. c. 32, § 12(2)(d) as the spouse, former spouse who has not
remarried, child, father, mother, sister or brother of the member.
To Be Completed by Witness of Choice of Beneficiary of
Accumulated Total Deductions.
Signature of Witness __________________________________________ Date ____________
Name of Witness (Print) ______________________________________
CLEAR
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