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
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
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
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