Fillable SHERIFFS RETIREMENT SYSTEM (SRS) MEMBERSHIP/DESIGNATION OF BENEFICIARY CARD (Rosebud County)

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SHERIFFS RETIREMENT SYSTEM (SRS) MEMBERSHIP/DESIGNATION OF BENEFICIARY CARD (Rosebud County)

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The SHERIFFS RETIREMENT SYSTEM (SRS) MEMBERSHIP/DESIGNATION OF BENEFICIARY CARD (Rosebud County) form is 1 page long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for Rosebud County

BROWSE ROSEBUD COUNTY (MT) FORMS

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Montana Public Employee Retirement Administration
PO Box 200131 • Helena MT 59620-0131
(406) 444-3154 • Toll Free (877) 275-7372
http://mpera.mt.gov
* For identification and tax purposes. §19-2-403(8) MCA, 26 USC §6109.
SHERIFFS’ RETIREMENT SYSTEM (SRS)
MEMBERSHIP/DESIGNATION OF BENEFICIARY CARD
Original signatures are required. MPERA cannot accept faxed or photocopies of this form.
This form must be filed with MPERA before any changes will take effect.
MEMBER INFORMATION
Last Name
First Name, MI
Social Security Number*
- -
Date of Birth
/ /
Gender
M F
Employing Agency
Employer Number (MPERA use only)
Mailing Address
City
State
Zip Code
Daytime Phone Number
( )
Email Address
Type Of Position (check one): Sheriff Under Sheriff Deputy Sheriff Detention Officer
Gambling or Criminal Investigator
PRIMARY AND/OR CONTINGENT BENEFICIARY DESIGNATION
I wish to retain SRS beneficiary designation currently on file with MPERA.
Completion of this section revokes all prior beneficiary designations unless you are prohibited from changing your
beneficiary by a valid temporary restraining order issued pursuant to § 40-4-121, MCA. 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 (NOTE: Any designated trust must already be in existence—this form cannot create a trust.)
Name of Trust, Charity or Estate Trustee/Contact Name Address
REQUIRED SIGNATURES
Member Signature
Date
Witness Name Printed (not a beneficiary)
Signature
Date
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SHERIFFS RETIREMENT SYSTEM (SRS) MEMBERSHIPDESIGNATION OF BENEFICIARY CARD (Rosebud County)

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Completed 18 July 2020

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