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To Whom It May Concern, The Public School

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To Whom It May Concern,
The Public School Retirement System of Missouri (PSRS) provides valuable protection to your
beneficiaries if your death occurs prior to retirement.
This form establishes your beneficiary designation with PSRS prior to your retirement. It must be
properly completed and on file with PSRS in order to be effective.
Please read the brochure, Protecting Those You Care About, before completing this form. This brochure
provides information to assist you in making an informed decision with regard to your beneficiaries, such
as survivor benefits, naming joint or multiple beneficiaries, and how your beneficiaries are determined by
Missouri law when your designation is voided due to a change in life status (marriage, divorce, birth or
adoption of a child).
You may name as your beneficiary: 1.) an individual, 2.) a legal entity such as a church, school or
organization, 3.) your estate, or 4.) a legally established trust. If the space provided here is not sufficient
for your desired designations, you may include a dated attachment, which bears your original signature.
Be proactive in updating your beneficiary designation and provide complete information to help ensure
any benefit payable at your death is distributed in accordance with your wishes. PSRS will acknowledge
receipt of this form. You may also view your beneficiary designation on the PSRS website,
www.psrs-peers.org.
If you have questions about designating beneficiaries or how to complete this form, we recommend
speaking with a PSRS representative by calling (800) 392-6848.
Sincerely,
Jana Taylor
Information and Records Management Supervisor
Enclosure
–
–
–
PRE-RETIREMENT BENEFICIARY DESIGNATION
Instructions:
Review the brochure, Protecting Those You Care About, and the information on the reverse before completing this form. Return the completed
form to the Public School Retirement System of Missouri (PSRS) at the address above.
Make sure you sign the form.
If the space provided is not sufficient for your desired designation, please include a dated attachment with your original signature.
Keep a copy for your records.
SECTION A MEMBER INFORMATION
First Name
Middle Name
Last Name
Member ID (or Last Four Digits of Your Social Security Number)
Account ID (if known)
Telephone
( )
City
State
ZIP
Email Address
SECTION B BENEFICIARY DESIGNATION
I hereby request and authorize the PSRS/PEERS Board of Trustees to pay any benefits due at my death to the primary beneficiary named below.
Payments to the first or second contingent beneficiary would only be made if the preceding beneficiary is deceased. I reserve the right to change my
beneficiary by filing a new
Pre-Retirement Beneficiary Designation
form. This designation supersedes and renders void my previous designation.
Primary Beneficiary
First Name
Middle Name
Last Name
Social Security Number
Date of Birth
Relationship to You
__
__
Mailing Address
City
State
ZIP
First Contingent Beneficiary
First Name
Middle Name
Last Name
Social Security Number
Date of Birth
Relationship to You
__
__
Mailing Address
City
State
ZIP
Second Contingent Beneficiary
First Name
Middle Name
Last Name
Social Security Number
Date of Birth
Relationship to You
__
__
City
State
ZIP
SECTION C MEMBER CERTIFICATION
I have reviewed the reverse side of this form, and I understand that: 1.) Upon a change in life status (marriage, divorce, birth or adoption of a child)
this beneficiary designation on file with the retirement office is automatically revoked in its entirety, and 2.) I must complete a new designation. If I
do not complete a new beneficiary designation, any benefit due at my death will be paid in accordance with Missouri law.
Digital Signatures Not Accepted – Original (Written) Signature Required
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To Whom It May Concern, The Public School

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Completed 20 November 2020

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