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Montana Public Employee Retirement Administration PC Box 200131 • Helena MT 59620-0131 (406) 444-3154 • Toll Free (877) 275-7372 http://mpera.mt.gov PUBLIC EMPLOYEES’ RETIREMENT SYSTEM (PERS) MEMBERSHIPIDESIGNATION OF BENEFICIARY FORM MEMBER INFORMATION Last Name First Name, Ml Social Security Number* Date of Birth Gender Employing Agency Employer Number (MPERA use only) “ “ EM__ElF Members Mailing Address City State Zip Code Daytime Phone Number Email Address ( ) PRIMARY ANDIOR CONTINGENT BENEFICIARY DESIGNATION Completion of this section revokes all prior beneficiary designations unless you are prohibited from changing your beneficiary by a valid temporary restraining order issued pursuant to § 40-4-1 21, MCA. You may designate one or more primary or contingent beneficiaries by using a separate line for each person. Contingent beneficiaries receive benefits only if all listed primary beneficiaries are deceased. If you list two or more primary (or two or more contingent beneficiaries) they will be treated on a share and share alike basis. If you prefer a different allocation, please specify. If you designate a trust, a charitable organization or your estate as a primary or contingent beneficiary, you will also need to complete the “Other Designation’ section. Primary Beneficiary - attach additional list if necessary. Full Name Gender Relationship Birth Date SSN* Allocation EM EF % EM EF % EM EF % Contingent Beneficiary (optional) - attach additional list if necessary. Full Name Gender Relationship Birth Date SSN* Allocation EM EF % EM EF % EM EF % Other Designation (NOTE: Any designated trust must already be in existence - this form cannot create a trust. Further, by designating a trust you verify that it is valid under state law; irrevocable on or before your death; and for the benefit of identifiable livinq person(s).) Name of Trust, Charity or Estate Trustee/Contact Name Address Tax Identification Number REQUIRED_SIGNATURES Member Signature Date Witness Name printed (not a beneficiary) Witness Signature Date Original signatures are required. MPERA cannot accept faxed or photocopies of this form. This form must be filed with MPERA before any changes will take effect. MBS-0044-0121-O1-OeeeeeeeOO * For identification and tax purposes. §19-2-403(8) MCA, 26 USC 6109.