AI_BENEFRM_200711 “An Affirmative Action/Equal Opportunity Employer”
CT TEACHERS’ RETIREMENT BOARD
165 CAPITOL AVENUE HARTFORD, CT 06106-1673
Toll Free 1 (800) 504-1102 Local (959) 867-6333 Fax (860) 241-9295
www.ct.gov/trb
ACTIVE/INACTIVE TEACHER BENEFICIARY FORM
Section 10-183(h) of the Connecticut General Statutes requires that monthly survivor benefits be paid to the statutory survivors of
members who die while active before any balance is paid to your designated beneficiary. This is true regardless of whom you
designated as your beneficiary. A statutory survivor includes but is not limited to a spouse and/or a minor child under the age of 18.
Refer to our Survivorship Benefits Before Retirement Bulletin
before completing this form (survivorship benefits are not available to
survivors of inactive members). This form supersedes and replaces any previous beneficiary designations. All items pertaining to
beneficiaries must be completed in order for the Connecticut Teachers’ Retirement Board (CTRB) to process the form; incomplete
forms will be returned.
▪ Include a complete list of all beneficiaries.
▪ Type or print clearly in ink and do not use white out.
▪ Do not submit an amended copy of a previous beneficiary form.
▪ You may name any living person, your estate, a trust, or a charitable organization as your beneficiary.
▪ At least one primary beneficiary must be named. If more than one primary beneficiary is named, the share of any beneficiary who dies before you
shall be divided equally among the surviving primary beneficiaries.
▪ A payment is made to a contingent beneficiary(ies) only if all primary beneficiaries die before you do.
▪ If you survive all of the beneficiaries named, payment would be issued to your estate.
▪ “Per Stirpes” designations (unnamed or unborn beneficiaries) are not accepted.
▪ All information must appear in the appropriate section of this form.
▪ To designate a trust as a beneficiary enter the name and date of the trust agreement in the Beneficiary section of this form; leave the Relationship
and Social Security sections of this form blank; and indicate Primary or Contingent.
▪ To designate your estate as a beneficiary enter the word “Estate” in the Beneficiary section of this form; leave the Relationship and Social Security
sections of the form blank; and indicate Primary or Contingent.
▪ Review your CTRB Member Annual Statement to verify your designated beneficiary election on our records.
MEMBER NAME (First Name, Middle Initial, Last Name)
Member Status: New Member Active Member Inactive Member
NEW MEMBERS AND ACTIVE MEMBERS: All demographic changes/corrections (name, address, date
of birth or social security number) must be submitted directly to your employer. Your employer will then
transmit the updated information electronically via their next monthly transmittal to CTRB.
NEW ADDRESS NAME CHANGE
BENEFICIARY NAME AND ADDRESS RELATIONSHIP SOCIAL SECURITY # CHECK ONE
Name:
primary
contingent
Address:
Name:
primary
contingent
Address:
Name:
primary
contingent
Address:
Name:
primary
contingent
Address:
Use additional Active/Inactive Teacher Beneficiary forms to designate additional beneficiaries.
If you have a spouse who you have not designated as a beneficiary, you need to check this box while you are actively
employed to waive the statutory survivorship benefits for your spouse in order for your designated beneficiary to receive the
funds in your account in the event of your death prior to your retirement.
CTR
B does not acknowledge receipt of individual forms. Please retain a copy for your records and forward this form by fax directly to CTRB
at the fax number above.
