Montana Public Employee Retirement Administration
PO Box 200131 • Helena MT 59620-0131
(406) 444-3154 • Toll Free (877) 275-7372
http://mpera.mt.gov
Form 1001 * For identification and tax purposes. §19-2-403(7) MCA, 26 USC § 6041A and 6109
PUBLIC EMPLOYEES’ RETIREMENT SYSTEM (PERS)
MEMBERSHIP/DESIGNATION OF BENEFICIARY CARD
MEMBER INFORMATION
Last Name
First Name, MI Social Security Number*
- -
Date of Birth
/ /
Gender
M F
Employing Agency Employer Number (MPERA use only)
Member’s Mailing Address
City
State Zip Code
Daytime Phone Number
( )
Email Address
PRIMARY AND/OR CONTINGENT BENEFICIARY DESIGNATION
I wish to retain the PERS beneficiary designation currently on file with MPERA.
Completion of this section revokes all prior beneficiary designations. You may designate one or more
primary or contingent beneficiaries by using a separate line for each person. Contingent beneficiaries receive
benefits only if all listed primary beneficiaries are deceased. If you list two or more primary (or two or more
contingent beneficiaries) they will be treated on a share and share alike basis. If you prefer a different
allocation, please specify. If you designate a trust (for the benefit of a natural living person only), a charitable
organization or your estate as a primary or contingent beneficiary, you will also need to complete the “Other
designation” section.
Primary Beneficiary - attach additional list if necessary.
Full Name Gender Relationship Birth Date SSN* Allocation
M F
%
M F
%
M F
%
Contingent Beneficiary (optional) - attach additional list if necessary.
Full Name Gender Relationship Birth Date SSN* Allocation
M F
%
M F
%
M F
%
Other Designation
Name of Trust, Charity or Estate Trustee/Contact Name Address
REQUIRED SIGNATURES
Member Signature
Date
Witness Name printed (not a beneficiary)
Signature Date
