Beneficiary Change Form - Option B (If Member Dies After Retirement)
Pursuant to Massachusetts General Laws, Chapter 32, Sections 11(2)(b) and 12(2)(b)
Form Last Revised: July, 2019 2
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 member of the
Retirement System, have chosen to be retired under the provisions of Massachusetts General Laws, Chapter 32, Section 12(2)(b)
("Option B"). I hereby request that the retirement board pay any sum payable under that section of the law to the beneficiary or
beneficiaries I have listed on the following page.
The amounts payable under Option B consist of:
• The payment of any accumulated deductions credited to a retired member's account in the annuity reserve fund
at the date of death.
• The amount of any pro-rata share of retirement allowance due to the member on the date of his/her death.
I understand that I may change this beneficiary designation at any time by filing a new Beneficiary Change Form - Option B.
Name of Retirement Board:
Address:
City/Town: Zip Code:
Telephone: Fax:
Retirement Board: Please enter your retirement board information here.
Member's Information:
***-**-___ ___ ___ ___
Member's Last Name Member's First Name Social Security # (last four)
Street Address:
City/Town: State: Zip Code:
Email:
Phone:
