Fillable Commonwealth of Massachusetts - State Board of Retirement - Beneficiary Change Form

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Commonwealth of Massachusetts - State Board of Retirement - Beneficiary Change Form

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Main Office: One Winter Street, 8th Floor, Boston, MA 02108 Phone: 617-367-7770 Fax: 617-723-1438 Toll Free (within MA): 1-800-392-6014
Regional Office: 436 Dwight Street, Room 109A, Springfield , MA 01103 Phone: 413-730-6135 Fax: 413-730-6139
mass.gov/retirement
THE COMMONWEALTH OF MASSACHUSETTS
State Board of Retirement
ONE WINTER STREET, 8TH FLOOR, BOSTON, MA 02108
BENEFICIARY CHANGE FORM
TO THE BOARD OF RETIREMENT: SSN#_____________________________
In accordance with the provisions of Section 11 of Chapter 32 of the Massachusetts General Laws
I, _______________________________________, a member of the State Employees’ Retirement System, hereby nominate the following-
named beneciary or beneciaries in the proportion designated or in the alternative other beneciaries to receive any sum referred to
in said Section 11 due at the time of my death: (The totals of all proportions for your primary and contingent beneciary(ies) MUST
equal 100% EACH.)
BENEFICIARY INFORMATION
Name:
Designation:
(Must check 1 box)
Primary, OR
Contingent
Proportion:*
(Must check 1 box)
ALL, OR
_______ %
(percent)
Date of Birth:
Street:
Relationship:
City, State, ZIP:
Beneciary Social Security #:
Name:
Designation:
(Must check 1 box)
Primary, OR
Contingent
Proportion:*
(Must check 1 box)
ALL, OR
_______ %
(percent)
Date of Birth:
Street:
Relationship
City, State, ZIP:
Beneciary Social Security #:
Name:
Designation:
(Must check 1 box)
Primary, OR
Contingent
Proportion:*
(Must check 1 box)
ALL, OR
_______ %
(percent)
Date of Birth:
Street:
Relationship:
City, State, ZIP:
Beneciary Social Security #:
Check here if additional beneciaries are listed on the back of this form
Please sign below:
Signature required by (1) the Member and (2) a Witness who is not listed as a beneciary.
Member Signature (required):
Date:
Member Address: Department/Agency:
Witness Signature (required):
Date:
* Please note that this form will be invalid if your witness is also listed as a beneciary on any part of this form.
Witness Printed Name/Address:
The types of payment to the beneciary(ies) you may designate with this form include:
Before your retirement:
• The payment of the accumulated total of deductions credited to your account in the annuity savings fund at the date of your death.
Following your retirement:
• The payment of any cash refund due at your death if your retirement was elected under Option (B).
Please note:
Election of a beneciary under Option (C), the survivorship allowance, is NOT made on this form. Such selection is made on
the Retirement Option Selection Form at the time of retirement.
The right to change any beneciary is reserved. This may be done by ling a new form. If you are naming contingent bene-
ciaries, please specify.
The totals of all proportions for your primary and contingent beneciary(ies) MUST equal 100% EACH.
A form with corrections or erasures will not be accepted. A form with no signatures will not be accepted.
The person designated as beneciary cannot be a witness to your signature.
1
2
*The totals of all proportions for your primary and contingent beneciary(ies) MUST equal 100% EACH.
ADDITIONAL BENEFICIARY INFORMATION
Name:
Designation:
(Must check 1 box)
Primary, OR
Contingent
Proportion:*
(Must check 1 box)
ALL, OR
_______ %
(percent)
Date of Birth:
Street:
Relationship:
City, State, ZIP:
Beneciary Social Security #:
Name:
Designation:
(Must check 1 box)
Primary, OR
Contingent
Proportion:*
(Must check 1 box)
ALL, OR
_______ %
(percent)
Date of Birth:
Street:
Relationship
City, State, ZIP:
Beneciary Social Security #:
Name:
Designation:
(Must check 1 box)
Primary, OR
Contingent
Proportion:*
(Must check 1 box)
ALL, OR
_______ %
(percent)
Date of Birth:
Street:
Relationship:
City, State, ZIP:
Beneciary Social Security #:
GENERAL INFORMATION:
• The nomination of one or more beneciaries may be changed from time to time by ling a new form.
• Payment or proportionate payments to any beneciary or beneciaries will be paid in one sum.
• A beneciary nominated by a minor must be of his kindred. If a minor is designated as a beneciary, payment will be made
to the conservatorship of such minor.
AFTER THE DEATH OF A MEMBER:
1. The amount of any accumulated total deductions credited to the member’s account in the annuity savings fund is payable in one
sum or in proportionate sums to the surviving beneciary or beneciaries, except that in any case where the deceased member
is survived by a widow and/or children eligible to receive benets under the provisions of Section 12B or 12(2)(d) an election by
such widow or by a conservatorship on behalf of such children to receive such benets shall have preference over the right of any
beneciary named on this form. This provision is not applicable after retirement allowance has become eective for a member.
2. The amount of any cash refund due under Option (B) shall be paid to the surviving beneciary or beneciaries. Payment to any
beneciary or beneciaries shall bar the recovery of such payment by any other person. If no beneciary has been named or if no
beneciary survives,any sum due at the death of a member shall be paid to the legal representatives of such member.
3. If the sum does not exceed $300 the State Board of Retirement may make payment, after the expiration of 90 days, to the
person or persons appearing in its judgment to be entitled thereto; provided that no written demand by a duly appointed
executor or administrator has been made, nor probate proceedings have been commenced. Any action taken by the State Board
of Retirement within the provisions of Section 11 shall constitute a legal settlement of all claims on account of amounts payable
under such section.
4. The prorated monthly amount due upon the death of the member under Option (A), Option (B) or Option (C) is payable to
the estate of member, unless otherwise determined by the Board. Any such payment will constitute a legal settlement of all such
claims and shall bar recovery by any other person.
5. If retired under Option C and you predecease the beneciary, two-thirds (2/3) of your benet will be payable to the eligible
beneciary on record. If your beneciary predeceases you, your benet will automatically be converted to Option A.
6. Separately, you may designate a single beneciary to receive a monthly survivor allowance calculated as if you had retired on
the date of your death pursuant to G.L. c.32, §12(2)(d). You may only designate certain individuals to be a beneciary for a survivor
allowance. The beneciary must be a spouse, child, parent, sibling, or former spouse who has not remarried. Designation of a
beneciary other than a spouse for this purpose must be done on a separate form. Please contact the State Retirement Board for
further information.
05/2018
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Commonwealth of Massachusetts - State Board of Retirement - Beneficiary Change Form

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Completed 20 May 2020

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