The Beneficiary Change Form allows a retired member to select a beneficiary(ies) to receive pay-
ment of any accumulated deductions remaining in his/her account when the member dies after
retirement. Keep in mind:
In order to select a Beneficiary to Receive a Return of Accumulated Total Deductions at
Member’s Death or a Option(D) Beneficiary, use the Beneficiary Selection Form (If
Member Dies Before Retirement).
Any person, persons or entity can be named as an Option(B) beneficiary.
Your selection on this form will supersede any earlier beneficiary(ies) selected.
If you divorce or your personal situation changes, you may wish to file a new form with
your retirement board.
Introduction
Beneficiary Change Form (Option B)
(If Member Dies After Retirement)
COMMONWEALTH OF MASSACHUSETTS | PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
WEB | WWW.MASS.GOV/PERAC
Beneficiary Change Form (Option B)
(If Member Dies After Retirement)
COMMONWEALTH OF MASSACHUSETTS | PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
WEB | WWW.MASS.GOV/PERAC
Retirement
Board: Please
place your address
and phone
number here.
Choice of Beneficiary to Receive a Return of Accumulated Total Deductions
Remaining in a Member’s Annuity Account at Member’s Death
I, (Print Name) , a retired member of the
Retirement System hereby request the Board of Retirement to pay any sum referred to in G.L. c. 32, §
12(2)(b)* due at my death to the following beneficiary or beneficiaries in the proportions designated.
I understand that I may change my beneficiary designation at any time by filing a new Beneficiary Change Form
(Option B).
*The types of payments covered under G.L. c. 32, § 12(2)(b) include:
The payment of any accumulated deductions credited to a retired member's account in the annuity reserve
fund at the date of death when the member's death occurs after his/her retirement.
The amount of any uncashed checks payable to a retired member at his or her death.
Any person or entity may be a beneficiary under G.L. c. 32, § 12(2)(b). 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
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