The Notice of Election of Benefits Under G.L. c. 32, § 12(2)(d) form allows an eligible spouse or
Option D beneficiary of a deceased member-in-service to select whether or not to receive a
lifetime allowance with dependent benefits, if applicable. If an eligible spouse or Option D
beneficiary chooses not to receive a lifetime benefit, the individual designated by the member
on the Beneficiary Selection Form, who may or may not be the eligible spouse or Option D
beneficiary, will receive a cash refund of the member’s total accumulated deductions.
l A spouse seeking to receive benefits under G.L. c. 32, § 12(2)(d) must also complete
the Affidavit To be Filed with the Retirement Board by Spouse Seeking Member
Survivor Benefits.
l The retirement board will calculate the benefit amounts.
Introduction
Notice of Election of Benefits Under G.L. c. 32, § 12(2)(d)
Form Last Revised: October, 2001
COMMONWEALTH OF MASSACHUSETTS | PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
WEB | WWW.MASS.GOV/PERAC
Notice of Election of Benefits Under G.L. c. 32, § 12(2)(d)
Form Last Revised: October, 2001
Retirement Board Date Received by the Retirement Board
The statements below set forth the conditions under which the specified payments and the continuance of
such payments will be made on account of the membership of of the
Retirement System.
Chapter 32 of the General Laws provides certain benefits to certain survivors of members of any retirement
system under G.L. c. 32, § 12(2)(d) whose deaths occur prior to the date they are actually retired.
Your failure to act within a ninety day period or by will preclude your election of the member
survivor allowance set forth below under CHOICE
1 and such failure will require the payment of a lump sum
cash refund of the late member’s account.
Please check either CHOICE 1 or CHOICE 2
CHOICE 1: To , spouse or G.L. c. 32, § 12(2)(d) beneficiary of the late
member, a member-survivor allowance of $ monthly payable throughout your life.
In addition to the monthly member-survivor allowance payable to you there will be paid for the benefit of the
children of the late member, if any, $120 per month for the first child and $90 per month for each additional
child who is:
l Under age eighteen or
l Over age eighteen and physically or mentally incapacitated from earning on the member’s date
of death or
l Over age eighteen and up to age twenty-two and a full-time student in an accredited
educational institution.
Payments for a child who is not a full time student will terminate upon his/her adoption, upon his/her reaching
age eighteen, unless he/she is physically or mentally incapacitated from earning, upon his/her marriage, whichever
first occurs, or upon his/her death.
CHOICE 2: Payment in one sum of a cash refund in the amount of $ to
, beneficiary of record of the late member, with the condition that such
payment constitutes a legal settlement of all claims on the account of the late member.
COMMONWEALTH OF MASSACHUSETTS | PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
WEB | WWW.MASS.GOV/PERAC
Retirement
Board: Please
place your address
and phone
number here.
4
Payments for a child over eighteen who is a full time student shall terminate upon his/her adoption, upon
his/her reaching age twenty-two, upon his/her ceasing to be a full time student, upon his/her marriage,
whichever first occurs or upon his/her death.
In the event of your death, and while there are eligible children as described above, there shall be paid to a
legal guardian for the benefit of such child or children an amount of $ per month, in addition to
the amounts payable on account of any such child or children.
I certify that I have read the statements about CHOICE 1 and CHOICE 2 and I hereby elect to
receive the above selected choice under the conditions set forth thereunder.
I sign this application 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 subject me to the loss of my benefits as well as civil and criminal penalties.
Applicant’s Signature _______________________________________ Date
Applicant’s Name (Print)
Social Security # Phone #
Address
Witness’ Signature _________________________________________ Date
Witness’ Name (Print)
Notice of Election of Benefits Under G.L. c. 32, § 12(2)(d) 2
Member’s Last Name First M.I. Social Security #
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