RS115
Revised: 08/2016
Page 1 of 4
Public Employee Retirement System of Idaho
P. O. Box 83720, Boise, ID 83720-0078
1-800-451-8228 208-334-3365 Fax 208-334-3805
www.persi.idaho.gov frontdesk@persi.idaho.gov
*RS115*
Beneficiary Designation
Purpose of the Form
Use this form to designate beneficiaries to receive your PERSI Base Plan and Choice 401(k) Plan death benefits.
Instructions
Read About Form RS115, attached.
Member Social Security Number Member PERSI ID Number*
* A PERSI ID is only required for members
with multiple PERSI accounts.
Member Information
NameFirst, Middle, Last
Mailing
Address
Street or P.O. Box
City
State
Zip Code
Email Address
Marital Status
Single
Married
Primary Beneficiary or Beneficiaries
Name Social Security or
Tax ID Number
Date of Birth Relationship to
You
Benefit % Nominate a custodian
under the Idaho UTMA
.0%
Check this box and
go to page 2.
.0%
Check this box and
go to page 2.
.0%
Check this box and
go to page 2.
.0%
Check this box and
go to page 2.
Secondary Beneficiary or Beneficiaries
Name Social Security or
Tax ID Number
Date of Birth Relationship to
You
Benefit % Nominate a custodian
under the Idaho UTMA
.0%
Check this box and
go to page 2.
.0%
Check this box and
go to page 2.
.0%
Check this box and
go to page 2.
.0%
Check this box and
go to page 2.
Member Acknowledgment
I understand the instructions and information under “About Form RS115.” I revoke all previous PERSI beneficiary
designations and request that any PERSI benefits payable after my death be made as indicated herein. I may change
this designation by filing a new form. This designation applies to my PERSI Base and Choice 401(k) Plan accounts.
Signature
Datemm/dd/yyyy
RS115
Revised: 08/2016
Page 2 of 4
Public Employee Retirement System of Idaho
P. O. Box 83720, Boise, ID 83720-0078
1-800-451-8228 208-334-3365 Fax 208-334-3805
www.persi.idaho.gov frontdesk@persi.idaho.gov
Beneficiary Designation (continued)
Member NameFirst, Middle, Last
Social Security Number
Custodian Nominations for Minor Beneficiaries under the Idaho Uniform Transfers to Minors Act
Use this section to nominate custodians and substitute custodians for minor beneficiaries under the Idaho Uniform
Transfers to Minors Act. Attach a copy of this page if nominating custodians for more than 4 minor beneficiaries.
Instructions
Write the minor beneficiary’s name in the top box.
Write the custodian’s name, Social Security number, address, and telephone number in the appropriate boxes. You
can nominate a substitute custodian to serve in the event the nominated custodian is unable. List each minor
beneficiary separately, even if you are nominating the same custodian for all minor beneficiaries.
Minor Beneficiary Name:
Custodian Information Substitute Information
Name:
Name:
SSN:
SSN:
Address:
Address:
City, St, Zip:
City, St, Zip:
Telephone:
Telephone:
Minor Beneficiary Name:
Custodian Information
Substitute Information
Name:
Name:
SSN:
SSN:
Address:
Address:
City, St, Zip:
City, St, Zip:
Telephone:
Telephone:
Minor Beneficiary Name:
Custodian Information Substitute Information
Name:
Name:
SSN:
SSN:
Address:
Address:
City, St, Zip:
City, St, Zip:
Telephone:
Telephone:
Minor Beneficiary Name:
Custodian Information Substitute Information
Name:
Name:
SSN:
SSN:
Address:
Address:
City, St, Zip:
City, St, Zip:
Telephone:
Telephone:
RS115
Revised: 08/2016
Page 3 of 4
Public Employee Retirement System of Idaho
P. O. Box 83720, Boise, ID 83720-0078
1-800-451-8228 208-334-3365 Fax 208-334-3805
www.persi.idaho.gov frontdesk@persi.idaho.gov
About Form RS115
Instructions
1 Complete the form and sign in blue or black ink.
2 Use whole percentages only.
3 If more space is needed, attach an additional signed and dated sheet of paper.
4 If any designated beneficiary is a minor, complete page 2 if you choose to nominate an adult custodian to receive
the funds for the minor. PERSI cannot pay a death benefit directly to a minor beneficiary.
5 Send the form to PERSI.
Note: The form is not valid unless signed, dated, and on file with PERSI.
Types of Beneficiaries
Primary beneficiary or beneficiaries. The first person or persons to receive death benefits when you die. If you
select one person only, he or she receives 100% of the benefits.
Secondary beneficiary or beneficiaries. Person or persons to receive death benefits if no primary beneficiary or
beneficiaries are alive when you die.
Default beneficiary. If PERSI does not have a beneficiary designation on file, death benefits are paid by law to
the following: (1) To your surviving spouse. (2) If you have no surviving spouse, to your estate. If you agree with
this default distribution and you have not previously submitted a beneficiary designation form, you do not need to
designate a beneficiary or submit this form. However, payment of death benefits could be delayed if PERSI has no
designation on file.
Notes About Designating Beneficiaries
Percentages must be in whole numbers. Do not use partial numbers. For example, use 33% not 33%.
Choose your beneficiaries carefully. Your PERSI funds might be your largest financial asset.
If you select two or more people as primary or secondary beneficiaries, indicate what percentage each is to receive
(the percentages must equal 100%).
You must list your children separately.
If you are designating one or more minors as beneficiary, you should specify how you want your death benefit
transferred if you die before the beneficiary reaches legal age of majority. PERSI cannot disburse the money to a
minor, so if you don’t nominate a custodian on this form, a court may have to appoint an adult to serve as
conservator of the funds. This form provides an easy and inexpensive way to transfer death benefits to a minor
through the Idaho Uniform Transfers to Minors Act (UTMA). This law enables you to nominate a custodian, and
substitute custodian, for your minor beneficiary, and authorizes PERSI to pay your death benefit to the custodian.
To nominate a custodian for a minor beneficiary, fill out page 2 of this form.
If you use the UTMA to nominate a custodian for your minor beneficiary, be aware that the legal age of majority
under the UTMA is 21, even though the statutory age of majority in Idaho is 18. If you die before your beneficiary
is 21 years of age, the money will go to and remain in the custodian’s care until the beneficiary reaches age 21.
Always provide full names (Mary Elizabeth Smith, not Mary Smith). For a married woman, use her full name (Mary
Elizabeth Smith, not Mrs. Bob Smith). Include the relationship to you.
This beneficiary designation is for PERSI Base Plan and Choice 401(k) Plan death benefits only. Any designations
you make for a will or an insurance policy do not substitute for the PERSI beneficiary designation.
Submit a new Beneficiary Designation (RS115) to PERSI if your marital status changes.
Complete a Member Name Change (RS111) if your name changes. If you are an active member, (working for a
PERSI employer and making contributions) give the form to your payroll clerk. If not, send the form to PERSI.
You can change your designations at any time by submitting a new Beneficiary Designation (RS115) to PERSI.
If you make an error, initial and date any corrections.
RS115
Revised: 08/2016
Page 4 of 4
Public Employee Retirement System of Idaho
P. O. Box 83720, Boise, ID 83720-0078
1-800-451-8228 208-334-3365 Fax 208-334-3805
www.persi.idaho.gov frontdesk@persi.idaho.gov
Minor Children, Trusts, Wills, and Charities as Beneficiaries
Minor children. To designate a minor child as a primary or secondary beneficiary, you should consider
transferring the money to a custodian for the child under the provisions of the Idaho Uniform Transfers to Minors
Act (UTMA). Using PERSI form RS115 page 2 meets the UTMA requirements.
Trusts. If you want to designate your Living Trust, show the date of the trust agreement and the name(s) of the
Trustee(s). If a bank or trust company is the Trustee, attach a separate document containing the Trustee’s
address. Provide PERSI with a copy of the trust’s registration, if available. The trust must have a tax ID number.
Wills. Write “the Executor of my Estate” or “the Administrator of my Estate” to designate your estate as
beneficiary. Do not name the executor, because the executor will be appointed later by the court.
Charities. You can name a specific charity as beneficiary. For more information about payment of death benefits
to charities, PERSI recommends that you consult with a qualified attorney.
Example 1
Primary Beneficiary or Beneficiaries
Name Social Security or
Tax ID Number
Date of Birth Relationship
to You
Benefit % Nominate a custodian
under the Idaho UTMA
Phillip Lee Thompson 000-01-0011 07-11-1937 Spouse 100.0%
Check this box and
go to page 2.
Check this box and
go to page 2.
Secondary Beneficiary or Beneficiaries
Name Social Security or
Tax ID Number
Date of Birth Relationship
to You
Benefit % Nominate a custodian
under the Idaho UTMA
John Allen Smith 000-08-0025 01-09-1997 Son 80.0%
Check this box and
go to page 2.
Rebecca Joan Smith 000-02-0220 01-02-1958 Sister 20.0%
Check this box and
go to page 2.
Example 2
Primary Beneficiary or Beneficiaries
Name Social Security or
Tax ID Number
Date of Birth Relationship
to You
Benefit % Nominate a custodian
under the Idaho UTMA
Sally Jones 000-03-0033 08-21-1994 Daughter 34.0%
Check this box and
go to page 2.
Alice Jones 000-04-0044 11-14-1991 Daughter 33.0%
Check this box and
go to page 2.
Andrew Jones 000-05-0055 02-29-1987 Son 33.0%
Check this box and
go to page 2.
Secondary Beneficiary or Beneficiaries
Name Social Security or
Tax ID Number
Date of Birth Relationship
to You
Benefit % Nominate a custodian
under the Idaho UTMA
The administrator of my
estate
Estate 100.0%
Check this box and
go to page 2.
Check this box and
go to page 2.
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