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Page 1 of 3 DRS MS 100 (R 8/10) Member/Retiree Information Name (Last, First, Middle) Social Security Number Mailing Address City State ZIP Daytime Phone Number ( ) E-mail Address Member/Retiree Beneficiary Designation PO Box 48380 Olympia, WA 98504-8380 w www.drs.wa.gov Toll Free: 1-[PHONE REDACTED] w Olympia Area: [PHONE REDACTED] w TTY: [PHONE REDACTED] Important: Please read instructions carefully before completing this form. Return form to DRS, not to your employer. Check one: c Public Employees’ c School Employees’ (non-teachers) c State Patrol c Judicial c Teachers’ c Law Enforcement Officers’ & Fire Fighters’ c Public Safety Employees’ Beneficiary Designation* - You must designate at least one primary beneficiary; do not designate yourself. If you make a mistake, initial next to your actual designation. Designation Beneficiary Information Relationship Must check one c Primary c Contingent Full Name of Person, Estate, Trust or Organization Mailing Address Social Security Number Date of Birth City State ZIP Must check one c Primary c Contingent Full Name of Person, Estate, Trust or Organization Mailing Address Social Security Number Date of Birth City State ZIP Must check one c Primary c Contingent Full Name of Person, Estate, Trust or Organization Mailing Address Social Security Number Date of Birth City State ZIP Must check one c Primary c Contingent Full Name of Person, Estate, Trust or Organization Mailing Address Social Security Number Date of Birth City State ZIP *If you are naming more than four beneficiaries please attach a separate sheet that is signed, dated and witnessed. Clear Form ---PAGE BREAK--- Page 2 of 3 DRS MS 100 (R 8/10) Witness Required – MUST be completed by a person, other than a beneficiary, who witnesses the member’s/ retiree’s signature. I, (print witness name - cannot be a beneficiary) witness that the above named member/retiree signed this document. Signature Date Mailing Address City State ZIP Department of Retirement Systems (DRS) requires that you provide your Social Security number for this form. • DRS will use your Social Security number as a reference number and to ensure that any funds disbursed under your account are correctly reported to the IRS. • DRS will not disclose your Social Security number unless required by law. • Internal Revenue Code Sections 6041(a) and 6109 allow DRS to request your Social Security number. Signature Required – MUST complete in full. I, (print name) 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 revokes any prior designations that I have made. Signature Date Beneficiary Designation for One-Time Duty-Related Death Benefit F F I designate the Beneficiary(ies) listed on page one. Designation Beneficiary Information Relationship Must check one c Primary c Contingent Full Name of Person, Estate, Trust or Organization Mailing Address Social Security Number Date of Birth City State ZIP Must check one c Primary c Contingent Full Name of Person, Estate, Trust or Organization Mailing Address Social Security Number Date of Birth City State ZIP Must check one c Primary c Contingent Full Name of Person, Estate, Trust or Organization Mailing Address Social Security Number Date of Birth City State ZIP If you have insurance coverage through the Washington State Public Employees Benefits Board (PEBB), we may share your information with PEBB to better serve you. ---PAGE BREAK--- Page 3 of 3 DRS MS 100 (R 8/10) Instructions and General Information for Member/Retiree Beneficiary Designation Use this form to designate or change the person, estate, trust or organization to receive any money due from your retirement account at the time of your death. Please print in dark ink, make a copy of the completed form for your records, and return it to DRS. Do not use felt tip pens. Before you complete the form, please note: • This is one of the most important documents associated with your retirement account. Read and complete all sections carefully. If you have any questions, please call us at 1-[PHONE REDACTED]. • Your retirement plan may have provisions that limit your beneficiary designation. Check your handbook (available online at www.drs.wa.gov) for details. • We will pay any benefits due after your death based upon the laws in effect on the date of your death. A beneficiary designation may be invalidated in certain circumstances. See your plan handbook for more information. • If you are receiving a survivorship benefit from someone else’s DRS retirement plan, call us to request a Beneficiary Designation for Persons Receiving Survivor Benefits. • If you have money in more than one retirement system, you must complete a separate form for each system. When filling out your beneficiary designation(s): • If you name a person, always show that individual’s legal given name. For example: MARY K. DOE, not Mrs. Robert Doe. • If you designate a trust, your trustee will be required to provide DRS with a full copy of the trust document at the time of your death. • Please be aware that a beneficiary under the age of 18 will not be allowed to make claim until reaching legal age. A claim cannot be made on behalf of a child without court-issued Letters of Guardianship. • The one-time duty-related death benefit is separate from your retirement benefit and is available if death occurs as the result of injuries sustained during employment or an occupational disease or infection that arose naturally and proximately out of employment. Judicial Retirement System members are not eligible for this benefit. Signing the form: • Another person (other than your beneficiary) must witness your signature on this document and complete the witness section. • If your signature can only be made by mark, it must be witnessed by two individuals who sign in the witness section of the form and initial next to the mark. • An attorney-in-fact cannot sign for you unless the Power of Attorney documents specifically grant the power to designate a beneficiary. Submitting the form: • Your beneficiary designation is not valid until it is fully complete, signed and received by DRS. Please submit it directly to DRS, not to your employer. • If you are the Power of Attorney submitting this form you will also need to send the following: 1. A photocopy of the Power of Attorney document that grants you the power to designate a beneficiary. 2. Affidavit of Attorney-in-Fact completed and notarized. You can access this form from our Web site at www.drs.wa.gov under forms.