Fillable University Support Staff Enrollment Form

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University Support Staff Enrollment Form

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KPERS-7/99 Rev. 4/11
DESIGNATION OF BENEFICIARY
Important – The beneciary designations on this form replace all previous designations. Read instructions on page 3. If you
have more beneciaries than spaces in any category, please use an Additional Beneciaries page. Do not attach plain paper or
continue on the back of this form. Additional pages must be attached to this completed form to be valid.
Mark this box if you are using additional pages.
Contact Us – toll free: 1-888-275-5737 • phone: 785-296-6166 • fax: 785-296-6638
e-mail: kpers@kpers.org • web site: www.kpers.org • mail: 611 S. Kansas Ave., Suite 100, Topeka, KS 66603
Part A – Member Information
______-____-______ 2. Name (First, MI, Last):______________________________
1. Social Security Number:
____) _________________________ 4. Mailing Address: _________________________________
3. Telephone Number: (
_______________________________________ City, State, Zip: ___________________________________
5. Employer:
Part B – Primary Beneciary for KPERS Retirement Benets – Includes accumulated contributions
and interest. Each beneciary will share your benet equally. You must name a primary beneciary in this section.
_________________________________________________________ Social Security Number: ______-____-_____
Estate Trust Person (state relationship): __________________ Date of Birth: ____/____/____
Name:
_________________________________________________________ Social Security Number: ______-____-_____
Estate Trust Person (state relationship): __________________ Date of Birth: ____/____/____
Name:
_________________________________________________________ Social Security Number: ______-____-_____
Estate Trust Person (state relationship): __________________ Date of Birth: ____/____/____
Name:
_________________________________________________________ Social Security Number: ______-____-_____
Estate Trust Person (state relationship): __________________ Date of Birth: ____/____/____
Name:
_________________________________________________________ Social Security Number: ______-____-_____
Estate Trust Person (state relationship): __________________ Date of Birth: ____/____/____
Name:
Part C – Contingent Beneciary for KPERS Retirement Benets – Includes accumulated contributions
and interest. Each beneciary will share your benet equally if your primary beneciary(ies) is not living.
_________________________________________________________ Social Security Number: ______-____-_____
Estate Trust Person (state relationship): __________________ Date of Birth: ____/____/____
Name:
_________________________________________________________ Social Security Number: ______-____-_____
Estate Trust Person (state relationship): __________________ Date of Birth: ____/____/____
Name:
_________________________________________________________ Social Security Number: ______-____-_____
Estate Trust Person (state relationship): __________________ Date of Birth: ____/____/____
Name:
_________________________________________________________ Social Security Number: ______-____-_____
Estate Trust Person (state relationship): __________________ Date of Birth: ____/____/____
Name:
_________________________________________________________ Social Security Number: ______-____-_____
Estate Trust Person (state relationship): __________________ Date of Birth: ____/____/____
Name:
(more)
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RESET
SAVE
Member Name (Please Print): _____________________________ ______-____-_____
Social Security Number:
Part D – Primary Beneciary for Life Insurance (Active Members Only) – Complete this section if you want
to name a separate beneciary to receive your basic and optional group life insurance. Each beneciary will share your benet
equally. If you do not want to name a separate beneciary, leave this section blank and advance to Part F.
_________________________________________________________ Social Security Number: ______-____-_____
Estate Trust Person (state relationship): __________________ Date of Birth: ____/____/____
Name:
_________________________________________________________ Social Security Number: ______-____-_____
Estate Trust Person (state relationship): __________________ Date of Birth: ____/____/____
Name:
_________________________________________________________ Social Security Number: ______-____-_____
Estate Trust Person (state relationship): __________________ Date of Birth: ____/____/____
Name:
_________________________________________________________ Social Security Number: ______-____-_____
Estate Trust Person (state relationship): __________________ Date of Birth: ____/____/____
Name:
_________________________________________________________ Social Security Number: ______-____-_____
Estate Trust Person (state relationship): __________________ Date of Birth: ____/____/____
Name:
Part E – Contingent Beneciary for Life Insurance (Active Members Only) – For basic and optional group life
insurance. Each beneciary will share your benet equally if your primary beneciary(ies) is not living.
_________________________________________________________ Social Security Number: ______-____-_____
Estate Trust Person (state relationship): __________________ Date of Birth: ____/____/____
Name:
_________________________________________________________ Social Security Number: ______-____-_____
Estate Trust Person (state relationship): __________________ Date of Birth: ____/____/____
Name:
_________________________________________________________ Social Security Number: ______-____-_____
Estate Trust Person (state relationship): __________________ Date of Birth: ____/____/____
Name:
_________________________________________________________ Social Security Number: ______-____-_____
Estate Trust Person (state relationship): __________________ Date of Birth: ____/____/____
Name:
_________________________________________________________ Social Security Number: ______-____-_____
Estate Trust Person (state relationship): __________________ Date of Birth: ____/____/____
Name:
Part F – Member Signature – Only the member may designate a beneciary. Conservators, guardians and those with
power of attorney cannot name a KPERS beneciary. Member’s signature must be witnessed by a disinterested party. Witness
may not be a beneciary. *Second witness required only if member signs with an “X.”
______________________________________________________________ Month/Day/Year: ____/____/____
Member Signature:
______________________________________________________________ Month/Day/Year: ____/____/____
Witness Signature:
_____________________________________________________________ Month/Day/Year: ____/____/____*Witness Signature:
Who Can You Name as Beneciary?
You can choose:
• A living person.
• A trust.
• Your estate.
• Any combination of these options.
You cannot name a church or other charitable organi-
zation as a beneficiary.
If you choose more than one beneficiary, each will
share your benefits equally. You can name separate
beneficiaries for your retirement benefits and life insur-
ance. You can also name a contingent beneficiary to
receive your benefits if your primary beneficiary is not
living. Only members can complete the designation
form. Conservators, guardians and those with power
of attorney cannot select or change a KPERS benefi-
ciary. Each time you complete a beneficiary form, it
cancels all those you have previously completed. Every
time you complete the form, fill in both the primary
and contingent beneficiary sections if you intend to
have a contingent beneficiary. If you complete only the
contingent section and leave the primary blank, you
will have no primary beneficiary, even if a past form
names one. The Board of Trustees recognizes only
those designations received in the Retirement System
office before your death.
Important: You must name a primary beneficiary for
retirement benefits in Part B. If no primary or contin-
gent beneficiary is living at the time of your death, your
retirement benefits will be paid according to the line of
descendency in K.S.A. 74-4902(7).
What Your Beneciary Receives
Your primary beneficiary for retirement benefits will
receive your contributions and interest, or possibly a
monthly benefit if your spouse is your sole primary
beneficiary (see Surviving Spouse Benefit). He or she
will also receive any basic and optional group life insur-
ance you have unless you name a separate beneficiary
for your life insurance.
Surviving Spouse Benet (Spouse as Sole
Primary Beneciary)
If you die before retirement, your spouse can choose
a monthly benefit for the rest of his or her life, instead
of receiving your returned contributions and interest.
You must have designated your spouse as your sole
primary beneficiary for retirement benefits.
Situation #1 If you were eligible to retire, your spouse
begins receiving a monthly benet immediately.
Situation #2 If you were not yet eligible to retire but had
ten years of service, your spouse begins
receiving a monthly benet when you
would have reached age 55.
You can name contingent beneficiaries or separate
beneficiaries for your life insurance without affecting
this benefit option.
Naming a Trust or Your Estate
If you name a trust, provide the name of the trust (e.g.,
Your Name, Trust #1). If you name your estate, write
“Estate of (Your Name)” or “My Estate.” You can name
another primary or contingent beneficiary in addition
to your estate or a trust, and each will share your ben-
efit equally.
Naming Additional Beneciaries
If you need to name more beneficiaries than space
allows, please use an Additional Retirement or Life
Insurance Beneficiaries page. This page must be with
your completed Designation of Beneficiary form to be
valid. You can download additional pages at www.
kpers.org or get one from your designated agent.
Inactive Members
Your beneficiary will receive your accumulated contri-
butions and interest, or your spouse can receive the Sur-
viving Spouse Benefit if you meet the criteria. Inactive
members are not eligible for group life insurance and
do not need to name a beneficiary in Part D or Part E.
Membership in More Than One Retirement
System (KPERS, KP&F, Judges, Board of Regents)
If you are a member of more than one KPERS-admin-
istered retirement system (KPERS, KP&F, Judges), this
beneficiary designation will become your designation
for all systems. If you are a Board of Regents member
and have KPERS service credit, this form designates
beneficiaries for KPERS benefits, not your Board of
Regents benefits.
For additional information on designating a beneficiary,
visit www.kpers.org or refer to your membership guide.
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University Support Staff Enrollment Form

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Completed 12 March 2020

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