Return completed form to:
Post Office Box 48380
Olympia, WA 98504-8380
Toll Free: 1-800-547-6657
Local:
360-664-7000
TDD:
360-586-5450
Washington State
Department of Retirement Systems (DRS)
Benefciary Designation
Check one:
Instructions:
Please type or print in dark ink and return completed form to DRS. Use this form to designate or change
your benefciary(ies) with the retirement system indicated above. The designated benefciary(ies) will receive any monies
due at the time of your death. If you have money in more than one retirement system, you must complete a separate form
for each system.
Section Two: Benefciary Designation –
You must designate at least one primary benefciary.
Your
designated primary and contingent beneficiary(ies) may be a person(s), estate, trust, or organization. If a trust is named, the legal
documentation must be submitted with this form. For each beneficiary, check whether you wish to make that person or entity a primary or
contingent beneficiary. When naming a person, always show given names. For example: MARY K. DOE (not Mrs. Robert Doe).
You may designate more than one beneficiary. If you do, the funds will be divided equally among all named beneficiaries unless otherwise
specified or required by law. Your primary beneficiary(ies) will receive any monies in your account at the time of your death. If your primary
beneficiary(ies) is(are) unable to accept the distribution, your contingent beneficiary(ies) will receive the distribution.
DRS MS 100 (R 08/07)
Continue, reverse side MUST be completed. > > > > >
Designation
Full name of persons or estate (trusts below)
Relationship
Address
Primary
Street
Social Security #:
Date of Birth:
-
-
City
State
Zip
Primary Contingent
Must check one
Street
Social Security #:
Date of Birth:
-
-
City
State
Zip
Primary Contingent
Must check one
Street
Social Security #:
Date of Birth:
-
-
City
State
Zip
Designation
Trust or organization (attach documentation)
Trustee or
Administrator
Address
Primary Contingent
Must check one
Street
Tax ID #:
City
State
Zip
x
Important:
Your benefciary designation may be limited by your specifc retirement plan, see your plan handbook for
details. Your designation will be invalidated by marriage, divorce, or reestablishment of membership following withdrawal
or retirement. Make a copy of your benefciary designation and review it periodically to ensure that it is still valid.
Section One: Member/Retiree/Survivor Information
Last name
First name
Middle name
Social Security number
Mailing address
City
State
Zip
Telephone number (daytime)
Telephone number (evening)
Are you retired with DRS?
Yes
No
If you are a survivor of a retiree, please list the retiree’s name and Social Security number.
Retiree’s Last name
First name
Middle name
Retiree’s Social Security number
PERS
SERS
TRS
PSERS
LEOFF
WSPRS
JRS
Section Four: Signature –
MUST complete in full.
If the signature can only be made by mark, it must be witnessed by two persons
who sign the form. The two witnesses must sign in the witness section and initial in the certification section if marked with an “X.”
I,
,
hereby direct that any monies related to my account, unless otherwise specified or
required by law, will be paid in equal shares to any primary beneficiaries named on this form who survive me, but if none survive, such monies
will be paid in equal shares to any contingent beneficiaries named on this form who survive me. I hereby certify that I have read and understand
the instructions to this form and that all of the information I have entered on this form is true and complete. Submission of this document evokes
any prior designations that I have made.
Section Five: Witness –
MUST be completed by a person, other than a benefciary, who witnesses the member’s signature.
To
protect members from fraudulent claims, it is required that another person witness the member’s signature on this document and complete and
sign this section. A beneficiary cannot sign as a witness.
I,
, am witness that the above named member completed and signed this document.
Signature
Date
Signature
Date
Street
City
State
Zip
(print name in dark ink)
(print witness name -
cannot be benefciary
- in dark ink)
This form requests that you provide your Social Security number. Internal Revenue Code Sections 6041 (A), and 6109 authorize the Department of Retirement
Systems (DRS) to solicit your Social Security number.
•
The disclosure of your Social Security number to DRS is mandatory.
•
DRS will use your Social Security number to ensure that any amounts disbursed under your account are properly reported to the Internal Revenue
Service and as a reference number for tracking all data with regard to your retirement account.
•
DRS will not disclose your Social Security number to any party unless required by law.
Section Three: Benefciary Designation for $150,000 Death Beneft
If your death occurs as a result of injuries sustained during the course of employment or an occupational disease or infection that arose naturally
and proximately out of employment, a $150,000 death benefit is available. Eligibility for this benefit is determined by the Department of Labor
and Industries. You may designate the same beneficiary(ies) listed in Section Two by checking the box by the statement below -
OR
- you may
designate a new beneficiary by completing the requested information. If you designate more than one beneficiary for the $150,000 benefit, it will
be divided equally among the named beneficiaries unless otherwise specified or required by law. If there is no designated beneficiary still living at
the time of your death, the death benefit will be paid to your surviving spouse. If there is no surviving spouse, the benefit will be paid to your legal
representative.
Note:
JRS members and survivors of all retirement systems are NOT eligible for this beneft and should NOT complete Section Three.
I designate the beneficiary(ies) named in Section Two to be the same beneficiary(ies) eligible for the $150,000 death benefit.
Designation
Trust or organization (attach documentation)
Trustee or
Administrator
Address
Primary Contingent
Must check one
Street
Tax ID #:
City
State
Zip
Designation
Full name of persons or estate (trusts below)
Relationship
Address
Primary Contingent
Must check one
Street
Social Security #:
Date of Birth:
-
-
City
State
Zip
OR
