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BROWSE LUNA COMMUNITY COLLEGE FORMS

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Widowed
Divorced
Married, previously divorced
Married
Single
Marital Status:
555-123-3456
Telephone Number
87505
Zip
NM
State
OPTIONAL
Previous Name (if applicable)
JOHN
First Name
Santa Fe
City
SMITH
Last
Name
1234 Main Street
Address
123-456-0000
Social Security Number
Date of Birth
01/01/1965
Female
Male
Beneficiary Change
New Form
Section I: Member Information
Please check:
My Commission Expires
Notary Public
State of , County of:
Subscribed and sworn to before me by on the day of , 20 .
Notary
Stamp
Date
Spouse Signature
Notary Public
Mandatory: If you are married and designating someone other than your spouse, this portion MUST be signed by your spouse in
the presence of a Notary Public.
Failure to do so will result in an incomplete and returned form.
Section V: Spousal Consent: I hereby certify that I am the spouse of the above named Member; and that I have read the Designation of
Benefic
iary form as completed and signed by my spouse; and I hereby freely consent to the beneficiary designation
made
herein. I understand beneficiary payment, if any, will be made to such beneficiary or beneficiaries named on this form.
*READ INSTRUCTIONS BEFORE COMPLETING*
Beneficiary Designation—Form 42
Rev. 11/19
Form must be filled out using blue or black ink only. Copies and/or Forms with white-out will be rejected.
~ Complete Section II or III. Do not complete both. ~See instructions.
Return completed form(s) to: PO Box 26129 Santa Fe, NM 87502-0129 1(866)691-2345 or (505) 827-8030
Check here if you are married and designating someone other than your spouse as a Beneficiary.
Date
Member Signature
Section IV: Member Authorization
I hereby declare that all of the information provided is true and complete to the best of my knowledge.
Beneficiary Address: Telephone Number:
City:
State: Zip:
Percentage allocation: (If no percentage is indicated the proceeds will be split evenly among those beneficiaries named.)
Date of Birth
Relationship:
Spouse, daughter, son, organization, etc.
Social Security Number:
Name:
CAN be a trust
Section III: Beneficiary Information: The beneficiary listed in Section III will receive a one-time lump sum payment. By
listing a beneficiary in section III you hereby
reject Option B coverage, as described in 22-11-29 (F), and your beneficiary
will not receive a lifetime monthly benefit upon your death.
Relationship:
Spouse, daughter, son, etc. Date of Birth
Beneficiary
Address: Telephone Number:
City: State: Zip:
Social Security Number:
Name:
Cannot be a trust
Section II: Beneficiary Information: By listing a beneficiary in section II, you are hereby giving your beneficiary the option to
select a lifetime benefit (Option B coverage) or a one
-time lump sum payment upon your death
. (If you select this option, you
can only name one beneficiary and it must be a human being, not a trust.)
Select either Section II or Section III
Choose ONE Option
Choose ONE Option
Choose only ONE o
ption.
Forms with both options
selected out will be rejected.
All fields are mandatory for
the option you choose.
REQUIRED
A Notary is
REQUIRED for
designating someone
other than your
spouse!
To name multiple beneficiaries (Section III ONLY), see Addendum on 3
rd
page.
Beneficiary Designation—Form 42
Addendum
If attached, your spouse (if married) MUST sign in presence of a Notary
Public.
Member Name: John Smith (your name) Member SSN: 123-456-0000
Section III (a): Beneficiary Information Use this form if you are rejecting the Automatic Option B coverage for
your beneficiary and wish to list more than one beneficiary to receive a lump sum payment upon your death.
Name: Social Security Number:
Relationship: Date of Birth
Beneficiary Address: Telephone Number:
City: State: Zip:
Percentage Allocation: (If no percentage is indicated the proceeds will be split evenly among those beneficiaries named.)
Name: Social Security Number:
Relationship: Date of Birth
Beneficiary Address: Telephone Number:
City: State: Zip:
Percentage Allocation: (If no percentage is indicated the proceeds will be split evenly among those beneficiaries named.)
Name: Social Security Number:
Relationship: Date of Birth
Beneficiary Address: Telephone Number:
City: State: Zip:
Percentage Allocation: (If no percentage is indicated the proceeds will be split evenly among those beneficiaries named.)
Check here if you are married and designating someone other than your spouse as a Beneficiary.
Rev. 05/19
Date
Member Signature
Section IV(a): Member Authorization
I hereby declare that all of the information provided is true and complete to the best of my knowledge.
My Commission Expires
Notary Public
Subscribed and sworn to before me by on the day of , 20 .
Notary
Stamp
Notary Public
State of , County of:
Date
Spouse Signature
Mandatory: If you are married, and designating someone other than your spouse, this portion MUST be signed by
your spouse in the presence of a Notary Public.
Failure to do so will result in an incomplete and returned form.
Section V(a): Spousal Consent:
I hereby certify that I am the spouse of the above named Member; and that I have read the
Designation of Beneficiary form as completed and signed by my spouse; and I hereby freely consent to the beneficiary des
ignation
made herein. I understand beneficiary payment, if any, will be made to such beneficiary or beneficiaries named on this form.
This Section is ONLY
if you have multiple
beneficiaries. They will
NOT receive a lifetime
benefit.
A Notary is
REQUIRED for
designating someone
other than your
spouse!
REQUIRED
Return completed form to: PO Box 26129 Santa Fe, NM 87502-0129. 1(866) 691-2345 or (505) 827-8030
Instructions for Beneficiary Designation—Form 42
Form must be filled out using blue or black ink only. Copies and/or Forms with white-out will be rejected.
Do NOT complete if retired.
Failure to comply with the instructions will result in an incomplete and rejected form.
Active and inactive (non-retired) members covered by the New Mexico Educational Retirement Board must complete NMERB Form 42
to designate a beneficiary for their account.
See Section 22-11-2 (E) and 22-11-29 (F)(G) & (I) NMSA 1978 and Paragraph (E) & (F) of 2.82.5.13 and Paragraph (B) of 2.82.3.10 NMAC.
Complete Sections I, II or III and IV. If you are married, and designated someone other than your spouse, Section V
MUST be completed and signed by your spouse in the presence of a notary public. If section V is completed, a notary must
notarize this section. Incomplete and/or incorrect forms will be returned to you.
Section II Beneficiary Information Automatic Option B coverage: If you are vested (five or more years of
earned service credit) and die prior to retirement, your named beneficiary may select either a monthly lifetime
benefit (annuity) or a one-time lump sum payment. You can name only one beneficiary for Option B coverage.
Naming more than one beneficiary on this form automatically rejects the Option B coverage. Only a named
beneficiary may select the monthly benefit option, all other beneficiaries are only eligible for a one-time lump sum
payment.
Section III Beneficiary(ies) Information: If you opt out of Option B coverage and die prior to retirement,
your named beneficiary(ies) on this form will receive a one-time lump sum payment.
Complete Section II if you want your beneficiary to qualify for the Option B coverage, as described in §22-11-29 (F) NMSA
1978. Once you are vested (five or more years of earned service credit) and if you die prior to retirement your named
beneficiary will have the choice to either receive a monthly lifetime benefit or a one-time lump sum payment. If you die prior
to having earned five years of service credit, your named beneficiary will receive a one-time lump sum payment.
Complete Section III if you reject the Option B coverage, as described in 22-11-29 (F), for your beneficiary or want to name
more than one beneficiary. Please note that naming more than one beneficiary automatically rejects the Option B coverage
for your beneficiaries. If you want to name more than one beneficiary, you may complete the Beneficiary Designation
—Form 42 Addendum.
Please include any previous names you have had if applicable.
Beneficiary(ies) may be changed any time prior to retirement.
In the event of a divorce it is important that you review your existing Beneficiary Designation form to ensure that the desired
beneficiary(ies) are named. A divorce does not automatically remove your former spouse as your beneficiary. The
Beneficiary Designation Form-42 can be accessed at www.nmerb.org/downloadableforms. * Please be advised that
beneficiary selections are subject to any court orders regarding the division of the community property portion
of your retirement benefit due to divorce. Provide a divorce decree, if you divorced at any point during your NMERB
service.
If you have never earned prior NMERB service and you complete this Beneficiary Designation-Form 42 and are not
reported by any NMERB covered employer within 90 days, this form will be void and will be returned to you.
Upon employment with an NMERB covered entity, this form must be returned to the NMERB.
If you fail to submit a valid beneficiary designation form, any benefits payable upon your death will be paid
to your surviving spouse or domestic partner, or if none, in a one-time lump sum payment to your estate. Proof of
marital status or domestic partnership is required.
Rev. 05/19
*READ INSTRUCTIONS BEFORE COMPLETING*
Beneficiary Designation—Form 42
Rev. 12/19
Form must be filled out using blue or black ink only. Copies and/or Forms with white-out will be rejected.
~ Complete Section II or III. Do not complete both. ~See instructions.
Return completed form(s) to: PO Box 26129 Santa Fe, NM 87502-0129 1(866)691-2345 or (505) 827-8030
Check here if you are married and designating someone other than your spouse as a Beneficiary.
Section III: Beneficiary Information: The beneficiary listed in Section III will receive a one-time lump sum payment. By
listing a beneficiary in section III you hereby reject Option B coverage, as described in 22-11-29 (F), and your beneficiary
will not receive a lifetime monthly benefit upon your death.
Name:_________________________________________ Social Security Number________________________
Relationship:____________________________________ Date of Birth________________________________
Beneficiary Address:_________________________________ Telephone Number:_______________________
City: ________________________________________ State: Zip:_____________________
Percentage allocation: (If no percentage is indicated the proceeds will be split evenly among those beneficiaries named.)
Relationship:
Date of Birth
Beneficiary
Address: Telephone Number:
City: State: Zip:
Social Security Number:
Name:
Section II: Beneficiary Information: By listing a beneficiary in section II, you are hereby giving your beneficiary the option to
select a lifetime benefit (Option B coverage) or a one
-time lump sum payment upon your death. (If you select this option, yo
u
can only name one beneficiary and it must be a human being, not a trust.)
Date
Member Signature
Section IV: Member Authorization
I hereby declare that all of the information provided is true and complete to the best of my knowledge.
Select either Section II or Section III
Widowed
Divorced
Married, previously divorced
Married
Single
Marital Status:
Telephone Number
Date of Birth
Employer
Social Security Number
Zip
State
City
Address
Previous Name (if applicable)
First Name
Last Name
Female
Male
Beneficiary Change
New Form
Section I: Member Information
Please check:
My Commission Expires
Notary Public
State of , County of:
Subscribed and sworn to before me by on the day of , 20 .
Notary
Stamp
Date
Spouse Signature
Notary Public
Mandatory: If you are married and designating someone other than your spouse, this portion MUST be signed by your spouse in
the presence of a Notary Public.
Failure to do so will result in an incomplete and returned form.
Section V: Spousal Consent:
I hereby certify that I am the spouse of the above named Member; and that I
have read the Designation of
Beneficiary form as completed and signed by my spouse; and I hereby freely consent to the beneficiary designation made herein.
I understand beneficiary payment, if any, will be made to such beneficiary or beneficiaries named on this form.
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signature
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signature
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Section IV(a): Member Authorization
I hereby declare that all of the information provided is true and complete to the best of my knowledge.
Member Signature
Date
Mandatory: If you are married, and designating someone other than your spouse, this portion MUST be signed by
your spouse in the presence of a Notary Public. Failure to do so will result in an incomplete and returned form.
Section V(a): Spousal Consent: I hereby certify that I am the spouse of the above named Member; and that I have read the
Designation of Beneficiary form as completed and signed by my spouse; and I hereby freely consent to the beneficiary designation
made herein. I understand beneficiary payment, if any, will be made to such beneficiary or beneficiaries named on this form.
Spouse Signature
Date
Notary Public
State of ________________________, County of: _______________________
Subscribed and sworn to before me by __________________________________________________ on the day _____ of __________, 20 _____.
Notary Public
My Commission Expires
Rev. 05/19
Beneficiary Designation—Form 42
Addendum
If attached, your spouse (if married) MUST sign in presence of a Notary Public.
Member Name: ___________________________________ Member SSN: __________________________
Section III (a): Beneficiary Information Use this form if you are rejecting the Automatic Option B coverage for
your beneficiary and wish to list more than one beneficiary to receive a lump sum payment upon your death.
Name: _____________________________________ Social Security Number: ______________________
Relationship: _________________________________________ Date of Birth _______________________
Beneficiary Address: ___________________________________ Telephone Number: ____________________
City: ________________________________ State: ______________________ Zip: _____________________
Percentage Allocation: ___________ (If no percentage is indicated the proceeds will be split evenly among those beneficiaries named.)
Name: _____________________________________ Social Security Number: ______________________
Relationship: _________________________________________ Date of Birth _______________________
Beneficiary Address: ___________________________________ Telephone Number: ____________________
City: ________________________________ State: ______________________ Zip: _____________________
Percentage Allocation: ___________ (If no percentage is indicated the proceeds will be split evenly among those beneficiaries named.)
Name: _____________________________________ Social Security Number: ______________________
Relationship: _________________________________________ Date of Birth _______________________
Beneficiary Address: ___________________________________ Telephone Number: ____________________
City: ________________________________ State: ______________________ Zip: _____________________
Percentage Allocation: ___________ (If no percentage is indicated the proceeds will be split evenly among those beneficiaries named.)
Notary
Stamp
Check here if you are married and designating someone other than your spouse as a Beneficiary.
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Completed 20 September 2020

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