CODE § 7-14D-20)
4101 MacCorkle Avenue, SE
Charleston, WV 25304
304-558-3570 or 800-654-4406
Consolidated Public Rerement Board
Section 1: Member Information
Street Address City State
Date of Birth
I_____________________________________________, do hereby direct that in the event of my death before my annuity
effective retirement date, the Teachers’ Defined Benefit Retirement System be authorized and directed to pay the full amount
of my accumulated contributions, plus any amount equal to my members contributions, to the person(s) designated below, as
my named beneficiary(ies).
I further understand that if I am at least fifty (50) years old and have at least twenty-five (25) years of total service at the time
of my death, my surviving spouse will become entitled to a monthly annuity only if my spouse is designated as my sole
primary refund beneficiary (WV Code §18-7A-23(b)(1)). Said monthly annuity will be paid in lieu of my accumulated
contributions, and an amount equal to my members contributions, as stated above.
I reserve the right to change my beneficiary at any time prior to my retirement, my death or my withdrawal from membership.
I understand that my beneficiary/ies selected below is only effective if officially recorded on a TRS beneficiary form
approved by the Consolidated Public Retirement Board (CPRB) and said form must be on record in the CPRB's office and
completed in its entirety prior to my death.
Full Name of Beneficiary
Date of Birth
Note: You may elect to name multiple primary and/or secondary beneficiaries. If you wish to do so and need more space than is provided, attach
to this form a sheet of paper with your name and social security number; include all
beneficiary information required above, whether the
beneficiary is to be Primary or Secondary, plus the percent of the distribution each is to receive.
Once received and accepted by CPRB, this form supersedes any and all prior Beneficiary Designations for you under TRS.
SIGNATURE OF MEMBER: _____________________________________________ DATE: _____________________
SIGNATURE OF WITNESS: _____________________________________________ DATE: _____________________
other than named
beneficiary or member)
ADDRESS OF WITNESS: ___________________________________________________________________________
Updated July 2016