KPERS-7/99 Rev. 9/15DESIGNATION OF BENEFICIARY mportant – The be - PDF document

KPERS-7/99 Rev. 11/16DESIGNATION OF BENEFICIARYFor security reasons, do not submit form by e-mail. Important – You have the option to make beneciary changes in your online account at kpers.org. Changes online or with this form replace all previous designations. Read instructions on page 3. If you have more beneciaries than spaces in any category, please use an Additional Beneciaries 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 Part A – Member Information Social Security Number: ___________________________ 2. Name (First, MI, Last): _____________________________3. Telephone Number: ______________________________ 4. Mailing Address: _________________________________5. Employer: City, State, Zip: ___________________________________ Part B – Primary Beneciary for KPERS Retirement Benets – Includes accumulated contributions and interest. Each beneciary will share your benet equally. You must name a primary beneciary in this section. Social Security Number: __________________ Person (state relationship): ___________________ Estate Trust Date of Birth: ___________________________Name: _________________________________________________________ Social Security Number: __________________ Person (state relationship): ___________________ Estate Trust Date of Birth: ___________________________Name: Social Security Number: __________________ Person (state relationship): ___________________ Estate Trust Date of Birth: ___________________________Name: Social Security Number: __________________ Person (state relationship): ___________________ Estate Trust Date of Birth: ___________________________Name: Social Security Number: __________________ Person (state relationship): ___________________ Estate Trust Date of Birth: ___________________________ Part C – Contingent Beneciary for KPERS Retirement Benets – Includes accumulated contributions and interest. Each beneciary will share your benet equally if your primary beneciary(ies) is not living. Social Security Number: __________________ Person (state relationship): ___________________ Estate Trust Date of Birth: ___________________________Name: Social Security Number: Person (state relationship): ___________________ Estate Trust Date of Birth: ___________________________Name: Social Security Number: __________________ Person (state relationship): ___________________ Estate Trust Date of Birth: ___________________________Name: __________________ Person (state relationship): ___________________ Estate Trust Date of Birth: ___________________________Name: Social Security Number: __________________ Person (state relationship): ___________________ Estate Trust Date of Birth: (more) Member Name (Please Print):Social Security Number: _____________________________________________________________ Part D – Primary Beneciary for Life Insurance (Active Members Only) – Complete this section if you wantto name a separate beneciary to receive your basic and optional group life insurance. Each beneciary will share your benetequally. If you do not want to name a separate beneciary, leave this section blank and advance to Part F.Estate Trust Date of Birth:Social Security Number:Person (state relationship): Estate Trust Date of Birth:Social Security Number:Person (state relationship): Estate Trust Date of Birth:Social Security Number:Person (state relationship): Estate Trust Date of Birth:Social Security Number:Person (state relationship): Estate Trust Date of Birth:Social Security Number:Person (state relationship): ___________________________________________________________________________ ______________________________________________ Part E – Contingent Beneciary for Life Insurance (Active Members Only) – For basic and optional group lifeinsurance. Each beneciary will share your benet equally if your primary beneciary(ies) is not living.Estate Trust Date of Birth:Social Security Number:Person (state relationship): Estate Trust Date of Birth:Social Security Number:Person (state relationship): Estate Trust Date of Birth:Social Security Number:Person (state relationship): Estate Trust Date of Birth:Social Security Number:Person (state relationship): Estate Trust Date of Birth:Social Security Number:Person (state relationship): ___________________________________________________________________________ ______________________________________________ Part F – Member Signature – Only the member may designate a beneciary. Conservators, guardians and those withpower of attorney cannot name a KPERS beneciary. Member’s signature must be witnessed by a disinterested party. Witnessmay not be a beneciary. *Second witness required only if member signs with an “X.”Member Signature://Month/Day/Year: ________Witness Signature://Month/Day/Year: ________*Witness Signature://Month/Day/Year: ________ Who Can You Name as Beneciary? • A living person. • A trust. • Your estate. • If you choose more than one beneficiary, each will share ries for your retirement benefits and life insurance. You can also name a contingent beneficiary to receive your benefits if your primary beneficiary is not living. Only tors, guardians and those with power of attorney cannot select or change a KPERS beneficiary. : You must name a primary beneficiary for gent beneficiary is living at the time of your death, your retirement benefits will be paid according to the line of What Your Beneciary ReceivesYour 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 ance you have unless you name a separate beneficiary Surviving Spouse Benet (Spouse as Sole Primary Beneciary) Situation #1 If you were eligible to retire , your spouse begins immediately. Situation #2 If you were not yet eligible to retire but had , your spouse begins You can name contingent beneficiaries or separate beneficiaries for your life insurance without affecting Naming a Trust or Your EstateIf you name a trust, provide the name of the trust (e.g., “Estate of (Your Name)” or “My Estate.” You can name Naming a Minor Child as Beneciary Naming Additional Beneciaries Inactive Membersbutions and interest, or your spouse can receive the Surviving 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)For additional information on designating a beneficiary, visit kpers.org or refer to your membership guide. SAVE PRINT RESET SAVE RESET PRINT 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4