OR
BEN-001
Rev. 06/04
Enrollment
Member Name
1. ___
(Last Name, First Name, Middle Name)
Member SSN:
REEMPLOYED RETIREES - Completion of this section will not change the beneficiary on your retired account. This beneficiary designation
is for your renewed membership under FRS Pension Plan. Obtain Form FST-12 from the Division of Retirement if you wish to change the
beneficiary on your retired account. Only a beneficiary who qualifies as joint annuitant will be eligible for a monthly benefit upon your
death.
DROP PARTICIPANTS - Do not use this form to change your beneficiary. Obtain Form FST-12 from the Division of Retirement.
TRS & SCOERS MEMBERS - You must choose Section 1 Sequentially or Section 2 Jointly and name a beneficiary.
DESIGNATION OF BENEFICIARIES - CHOOSE ONLY ONE SECTION - COMPLETE SECTION 1, 2, or 3
GenderBirthdate
Primary Beneficiary
Relationship
Relationship
3.____
(Prior-Last Name, First Name, Middle Name)
Circle One: Female / Male
OR
Date
2.___
I CHOOSE TO HAVE BENEFITS PAID SEQUENTIALLY (IN THE ORDER NAMED) - Benefits will be paid to the first named
beneficiary.
GenderBirthdateSecond Contingent Beneficiary
I CHOOSE TO HAVE BENEFITS PAID JOINTLY -(PERCENTAGES SHOULD TOTAL 100%) Benefits will be divided and
payable as indicated below.
Relationship
Birthdate Gender
Primary Beneficiary Relationship Birthdate Gender
Relationship Birthdate GenderPrimary Beneficiary
%
Primary Beneficiary Relationship Birthdate Gender
%
Member Signature
Birthdate
Agency Number/Agency Name
I CHOOSE TO HAVE BENEFITS PAID IN ACCORDANCE WITH 121.091(8),F.S.,
AS FOLLOWS: Benefits from your account will
be paid: 1st to your spouse, 2nd to your living children (equally), 3rd to your parents (equally), and 4th to the legal representative of
your estate. If you are not survived by a spouse, the names of your survivors must be documented by court order. If you do not want
your benefits paid in this manner in the event of your death, complete either Section 1 or 2.
.
***TYPE OR PRINT ***
%
Florida Retirement System Pension Plan
Beneficiary Designation Form
Active Members Only
First Contingent Beneficiary
If the above does not meet your needs, attach a s igned and dated listing of your designated beneficiaries (in the above format). Please include the
relationship, birthday, gender, and percentage for each designated beneficiary.
OR
P.O. Box 9000
Tallahassee, FL 32315-9000
(850) 488-8837 Toll Free:(877) 377-3675
Fax:(850) 410-2196
DESIGNATION OF BENEFICIARY - FRS PENSION PLAN ONLY: Section 121.091(8), Florida Statutes, provides: "Each member may, on a form provided for that
purpose, signed and filed with the Division, designate a choice of one or more persons, named sequentially or jointly, as his or her beneficiary who shall receive the
benefits, if any, which may be payable in the event of the member's death pursuant to the provisions of this chapter. If no beneficiary is named in the manner provided
above, or if no beneficiary designated by the member survives the member, the beneficiary shall be the spouse of the deceased, if living. If the member'sspouseisnot
alive at his or her death, the beneficiary shall be the living children of the member. If no children survive, the beneficiary shall be the member's father or mother, if living;
otherwise, the beneficiary shall be the member's estate." If your designated beneficiary does not qualify as a joint annuitant, only a refund of any contributions you made
to the system will be paid at your death. Only a joint annuitant will be eligible to receive monthly benefits from your retirement account. A joint annuitant is your spouse;
your natural or legally adopted child who is either under age 25 or is physically or mentally disabled and incapable of self-support (regardless of age); or your parent,
grandparent, or a person for whom you are the legal guardian, provided such parent, grandparent, or person received one-half or more of their financial support from you
or is eligible to be claimed as a dependent on your federal income tax return. Effective January 1, 1999, a member's spouse will be the primary beneficiary
regardless of previous beneficiary designations unless a new Form BEN-001is completed subsequent to the marriage to the current spouse.
TRS or SCOERS MEMBERS: You must name a beneficiary to receive, sequentially or jointly, any benefits that may be payable upon your death prior to retirement.
You may name as your beneficiary any person, organization, your estate or trust, but only your spouse is eligible to receive a monthly benefit if you die prior to your
actual retirement after completing 10 years of creditable service.
You should keep your beneficiary designations current at all times. Any questions on designating beneficiaries should be directed to the Division by writing: Division of
Retirement, ATTN: Enrollment Section, Division of Retirement, P.O. Box 9000, Tallahassee, FL 32315-9000 or by calling 850/488-8837 or 877/FRS-ENRL
(877/377-3675). Completed forms may be faxed to (850) 410-2196.
Rule 60S-9.001, F.A.C.
*B7*
