THIRD CONTINGENT DESIGNEE NAME (First, Middle, Last)
TELEPHONE NUMBER
ADDRESS ZIP CODECITY AND STATE
RELATIONSHIP TO EMPLOYEE
SECOND CONTINGENT DESIGNEE NAME (First, Middle, Last)
TELEPHONE NUMBER
ADDRESS ZIP CODECITY AND STATE
RELATIONSHIP TO EMPLOYEE
STATE OF CALIFORNIA – STATE CONTROLLER’S OFFICE
DESIGNATION OF PERSON(S) AUTHORIZED TO RECEIVE WARRANTS
(GC § 12479)
STD. 243 (REV. 08/2011)
EMPLOYEE NAME (First, Middle, Last)
AGENCY LOCATION (City)NAME OF EMPLOYING STATE AGENCY
Pursuant to Section 12479 of the Government Code, I hereby designate the following person(s), trust, estate, or corporation which, notwithstanding any
other provision of the law, shall be entitled upon my death to receive all state warrants that would have been payable to me had I survived.
NOTE: Direct deposit payments are not subject to the provisions of this designation.
Important: This is NOT a designation for payment of death benefits or refund of employee retirement contributions. A form PERS-BSD-241,
Beneficiary Designation, must be completed to file a designation with the California Public Employees' Retirement System for death benefits.
PRIMARY DESIGNEE (Must be 18 years of age or older)
PRIMARY DESIGNEE NAME (First, Middle, Last)
TELEPHONE NUMBER
ADDRESS ZIP CODECITY AND STATE
RELATIONSHIP TO EMPLOYEE
I hereby revoke all designations that I have previously filed.
The primary designated person shall be the designated person that receives the warrants. If the primary designated person predeceases the employee, the
next designated person who survives the employee will receive the warrant(s).
FOR AGENCY/CAMPUS USE ONLY
REVIEWED BY THE PERSONNEL/PAYROLL OFFICE AND FILED
EMPLOYEE HOME ADDRESS
SIGNATURE OF AUTHORIZED OFFICER
CITY, STATE, ZIP CODE
DATETYPED NAME
EMPLOYEE SIGNATURE (Please sign in ink)
DATE SIGNED
This designation will remain in full force and effect during my
employment with any California state agency/campus until revoked in
writing by me.
INSTRUCTIONS
1. Complete this form; print clearly in ink or type all information
requested.
2. Show the full name of all designees; for example, “Mary Jane
Smith”, not Mrs. John E. Smith.
3. Specify the relationship of each person designated, such as wife,
husband, domestic partner, daughter, son, mother, father, parent,
friend, etc.
4. Verify that the form is complete and correct. No erasures or
corrections may be made in the name of the primary designee or
contingent(s). If any error has been made, complete a new form.
5. Sign the form in ink and submit to your personnel/payroll office.
A copy will be returned to you for your records.
6. You may change your designation at any time by filing a new form
STD. 243 with your personnel/payroll office.
7. You may completely revoke a designation at any time by submit-
ting either of the following with original signature: A new form
STD. 243 indicating “NONE” for the primary designee name or a
letter to your employer.
8. Inform your personnel/payroll office when a change occurs in your
primary designee’s or contingent’s address.
9. You may wish to file a new designation upon any change in your
marital or domestic partnership status.
CONTINGENT DESIGNEE(S) (Must be 18 years of age or older)
FIRST CONTINGENT DESIGNEE NAME (First, Middle, Last)
TELEPHONE NUMBER
ADDRESS ZIP CODECITY AND STATE
RELATIONSHIP TO EMPLOYEE
If the above-named designee does not file a written request with the personnel/payroll office of my employing state agency/campus for such warrants
within sixty (60) days after the date of my death, this designation shall be and become null and void.
