CalPERS Pre-Retirement Beneficiary Designation 0772

Complete all fields.

Provide your name as it appears on your Social Security card, as Your Name (First Name, Middle Initial, Last Name), with your Social Security Number or CalPERS ID.

Enter your Daytime Phone and Alternate Phone.

Enter your Address, City, State and ZIP.

Put your name and Social Security number or CalPERS ID at the top of every page.

In Section 2, if a percentage (%) is entered, make sure the total equals 100%.

Enter the Name of Primary Beneficiary (First Name, Middle Initial, Last Name) and the Birth Date (mm/dd/yyyy).

Enter the Relationship to You, the Percentage of Benefit and the Social Security Number or CalPERS ID.

Enter the Address, City, State and ZIP.

You may name as beneficiary any person or persons, a corporation, or your estate. Payment will be made to your estate only if probated.

You may designate a trust as your beneficiary; however, you must provide the name of the trust, the date of the trust, and the name and address where the trust is filed. It is not necessary to provide the name of the trustee.

To name additional primary beneficiaries, attach a blank sheet of paper with your additional beneficiary information. Provide the same beneficiary information as required on this form, and be sure to indicate that the beneficiary is primary. Sign and date the paper, and include your Social Security number or CalPERS ID.

You may designate or change your beneficiaries at any time by completing another Pre-Retirement Lump-Sum Beneficiary Designation form.

In Section 3, if a percentage (%) is entered, make sure the total equals 100%.

The benefit is paid to your named secondary beneficiary or beneficiaries upon the death of your primary beneficiary or beneficiaries.

Enter the Name of Secondary Beneficiary (First Name, Middle Initial, Last Name), Birth Date (mm/dd/yyyy), Relationship to You, Percentage of Benefit, Social Security Number or CalPERS ID, Address, City, State and ZIP.

To name additional secondary beneficiaries, attach a blank sheet of paper with your additional beneficiary information, and be sure to indicate that the beneficiary is secondary.

You must review and sign this acknowledgment if you are married or in a registered domestic partnership and you name someone other than your spouse or domestic partner as a beneficiary to receive any lump-sum benefits which may be payable upon your death.

In the Member Acknowledgment, sign Your Signature and enter the Date (mm/dd/yyyy).

If you name one or more other individuals as your beneficiary(ies) to receive a benefit listed (the group term life insurance benefit, the employer share benefit, or the return of any remaining member contributions), and your spouse or domestic partner does not consent at this time by signing the Spouse's or Registered Domestic Partner's Consent, CalPERS will award fifty percent (50%) of the community property share of such benefit to your spouse or domestic partner in the event of your death unless he or she waives his or her community property interest in such benefit at the time the benefit becomes payable.

Your spouse or registered domestic partner must read the Spouse's or Registered Domestic Partner's Consent.

In the Spouse's or Registered Domestic Partner's Consent, your spouse or domestic partner signs Your Spouse's or Domestic Partner's Signature and enters the Date (mm/dd/yyyy).

In the Spouse's or Registered Domestic Partner's Consent, your spouse or domestic partner does not have to sign this consent, and if he or she does sign, the consent is irrevocable.

If you answered yes to Are you legally married or in a registered domestic partnership?, your spouse or registered domestic partner must sign this beneficiary designation unless you have designated him or her as the sole primary beneficiary of any lump-sum benefits. Otherwise, you must complete and submit the Justification for Absence of Spouse's or Registered Domestic Partner's Signature form.

Are you legally married or in a registered domestic partnership? Yes or No.

If no, please indicate: Never Married or in Domestic Partnership; Divorced, Annulled, or Domestic Partnership Terminated; or Widowed.

You certify, under the penalty of perjury, that the information submitted hereon is true and correct to the best of your knowledge.

Sign Your Signature and enter the Date (mm/dd/yyyy).

Sign in the required field.

By this beneficiary designation, you revoke any previous designation you have filed.

Your marriage or domestic partnership, final dissolution or annulment of your marriage or the termination of your domestic partnership, or the birth or adoption of a child subsequent to the date this form is filed with CalPERS will automatically void this designation.

A designation filed after the initiation of dissolution or annulment of marriage or domestic partnership or legal termination of domestic partnership will not be revoked when the legal process is finalized.

Before submitting your completed form, be sure to make a copy to keep with your important retirement information.

In Section 6, per Government Code section 21261, your spouse or registered domestic partner acknowledges that he or she is aware of the designation made by you and states that he or she is the current spouse or registered domestic partner.

Your spouse or registered domestic partner signs the Signature of Spouse or Registered Domestic Partner and enters the Date (mm/dd/yyyy), and the Date of Marriage or Registered Domestic Partnership (mm/dd/yyyy).

You must complete a Justification for Absence of Spouse's or Registered Domestic Partner's Signature form if your spouse or registered domestic partner is unable to sign this form.

Mail to CalPERS Retirement Benefit Services Division, P.O. Box 942711, Sacramento, CA 94229-2711, or fax to (800) 959-6545.