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Montana Public Employee Retirement Administration PO Box 200131 • Helena MT 59620-0131 (406) 444-3154 • Toll Free (877) 275-7372 http://mpera.mt.gov Form 1006 * For identification and tax purposes. §19-2-403(7) MCA, 26 USC § 6041A and 6109 MUNICIPAL POLICE OFFICERS’ RETIREMENT SYSTEM (MPORS) MEMBERSHIP/DESIGNATION OF BENEFICIARY CARD MEMBER INFORMATION Last Name First Name, MI Social Security Number* - - Date of Birth / / Gender M F Employing Agency Employer Number (MPERA use only) Mailing Address City State Zip Code Daytime Phone Number ( ) Email Address STATUTORY BENEFICIARY Statutory Beneficiaries: Your statutory beneficiary is your spouse. If you have no spouse, your dependent children are your beneficiaries. - attach additional list if necessary. Full Name of spouse Gender Birth Date SSN* M F Full Name of dependent children (if no spouse) Birth Date SSN* M F M F M F Designated Beneficiary: A designated beneficiary receives benefits only if there is no statutory beneficiary. You may nominate one or more designated beneficiaries by using a separate line for each person. If you list two or more designated 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 (for the benefit of a natural living person only), a charitable organization or your estate as a primary or contingent beneficiary, you will also need to complete the “Other designation” section. I nominate the following designated beneficiaries to receive payment in the absence of any surviving spouse or dependent child: (use beneficiary's own last name, middle initial and first name) Full Name Gender Relationship Birth Date SSN* Allocation M F % M F % Other designation: Name of Trust, Charity or Estate Trustee/Contact Name Address REQUIRED SIGNATURES Member Signature Date Witness Name Printed (not a beneficiary) Signature Date