Alaska Form 02 1890 – Fill Out and Use This PDF

			Application for Retirement Beneits
		National Guard and Naval Militia Retirement System
				FOR OFFICE USE ONLY
			Division of Retirement and Beneits	Juneau: (907) 465-4460
	Toll-Free:	(800) 821-2251	P.O. Box 110203
				TDD: (907) 465-2805
	alaska.gov/drb		Juneau, Alaska 99811-0203	FAX: (907) 465-3086

I hereby apply for retirement beneits to which I may be entitled in accordance with the provisions of Section 222 through 228 of Alaska Statues 26.05 governing the Alaska National Guard and Naval Militia Retirement System. I understand that I may elect to defer receipt of my monthly payments until a later day. If deferred, beneits will not commence until the irst of the month following receipt of new application.

SECTION I. PERSONAL DATA

Member's Name (Last, First, M.I.)

Social Security Number or RIN

DEFERRAL ELECTION

					If deferred, I understand I have
	Marital Status r Married - Date _______________		r Single	Date of Birth	to reapply before beneits can
					commence.
	r	Divorced - Date ______________ r Widowed
	Work Telephone Number		Home Telephone Number

SECTION II. BENEFICIARY DESIGNATION

In the event of my death prior to receiving all monthly beneits due me, I understand that the remaining beneit will be paid in a lump sum to my beneiciaries. Place an "X" in the appropriate box to specify whether the beneiciary is primary or contingent. The "primary" beneiciary or beneiciaries will receive beneits if you die. The "contingent" beneiciary or beneiciaries will receive beneits ONLY if the primary is deceased. My beneiciaries are:

			Name (Last, First, M.I.)	Relationship	Date of Birth	Percentage
	r	Primary				%

Mailing Address (Street or P.O. Box, City, State, ZIP+4)

Check whether the beneiciary is the primary or contingent

	r	Primary	Name (Last, First, M.I.)	Relationship	Date of Birth	Percentage
	r	Contingent				%

Mailing Address (Street or P.O. Box, City, State, ZIP+4)

	r Primary		Name (Last, First, M.I.)	Relationship	Date of Birth	Percentage
	r	Contingent				%
	Mailing Address (Street or P.O. Box, City, State, ZIP+4)				Social Security Number

I hereby certify that the information provided on this form is true and correct to the best of my knowledge. I understand that any deliberate misrepre- sentation for the purpose of obtaining beneits is an offense punishable by law.

SECTION III. EMPLOYER USE ONLY Alaska National Guard and Naval Militia Veriication of Service

Records at this headquarters verify the following information in reference to this application:

1.Veriied total years of satisfactory military service: _________________________________________________________________________

2.Type of retirement: r Voluntary r Involuntary (Reason): __________________________________________________________

3.Total Alaska National Guard and Naval Militia service: ____________ and _________ as of (separation date) ________/_______/_________

Years

Months

Month

Day

Year

4.Individual is qualiied for ___________ months of retirement pay at $____________ per month.

02-1890 (Rev. 03/12)

g:/publications/forms/miscellaneous/02-1890.indd

INSTRUCTIONS

Applicants should complete Sections I and II and mail to the:

State of Alaska, Ofice of the Adjutant General

Department of Military and Veterans Affairs

P.O. Box 5800, Camp Denali

Fort Richardson, AK 99505-5800

If you are MARRIED, your spouse is automatically your 100% primary beneiciary unless they consent to another beneiciary, or your spouse is not entitled to beneits under the terms of a Qualiied Domestic Relations Order (QDRO). Your spouse's written consent may

be waived if:

•You were not married to your spouse during part of your NGNMRS service;

•You have been married for less than one year;

•You have been married for less than two years and you have established that you and your spouse are not living together; or

•Your spouse cannot be located.

Your spouse may waive entitlement to beneits by completing and signing the "Spouse's Consent" below before a notary public or an authorized plan representative. If another person is entitled to beneits under a QDRO, that person may waive entitlement to beneits

by completing and signing the "QDRO Consent" below before a notary public or an authorized plan representative.

If you are a SINGLE PARENT, there are death beneits that may be payable to your dependent child if you die before retirement. These beneits are only payable to your children if they are your designated beneiciaries. Because beneits cannot be paid di-

rectly to minor children, they will be paid to the children's parent or legal guardian, unless you establish a trust and designate the trust

as beneiciary for your children. You should NOT designate another person as beneiciary to receive your children's beneits.

SPOUSE'S CONSENT

I, ______________________________ , am the spouse of _______________________ . I understand that I may be

entitled to the death beneits that will be paid if my spouse dies. I understand that, depending upon the circumstances of my spouse's death, I may be eligible to receive a lump sum beneit.

QDRO CONSENT

I, ____________________________ , understand that if ________________________ dies, I am entitled to the death

beneits described in the QDRO case # _____________ signed by the judge on, _____________ which is on ile with

the Division of Retirement and Beneits.

By signing this consent, I agree to waive my rights to those beneits and consent to the naming of another beneiciary.

Signature Witnessed By a Notary or Postmaster:

A QDRO (qualiied domestic relations order) is a divorce or dissolution judgment under Alaska Statute 25.24.

Section III. Veriication and Certiication (Employer Use Only). (Please do not write in this section. Employer must complete and sign in this area.) Contact the Division of Retirement and Beneits regarding the following changes or information:

•Change of residence (mailing address)

•Change of payment address (warrant mailing address)

•Change of beneiciary designation

•Information regarding your retirement