Form Rs 5127 PDF Details

When active members of the New York State and Local Retirement System, encompassing both the Employees’ Retirement System and the Police and Fire Retirement System, consider the future of their ordinary death benefits, the RS 5127 form emerges as a critical document. Located at the Office of the New York State Comptroller in Albany, New York, this form must be completed with utmost care to ensure one's wishes regarding beneficiaries are clearly established. The RS 5127 form allows for the designation of both primary and contingent beneficiaries, ensuring that members can plan for the distribution of benefits in the event of their untimely demise. However, it's vital to understand that this form is exclusively for the use of active members—retirees must seek other avenues. The prerequisites demand the form to be signed, notarized, and filed with the retirement system prior to the member's passing for it to take effect. It emphasizes the importance of clarity in beneficiary designation, including instructions against naming the same individuals as both primary and contingent beneficiaries. Notably, the form also outlines specific instructions for members who wish to designate their estate or opt for distributions under special conditions, such as establishing trusts or guardianships. Each section of the RS 5127 form calls attention to the importance of meticulous completion, underscoring the importance of privacy and legal compliance in managing retirement benefits. As such, abiding by the instructions—like using only blue or black ink and avoiding any form alterations—becomes paramount, reflecting the rigorous standards maintained by the New York State and Local Retirement System in safeguarding its members' posthumous benefits.

QuestionAnswer
Form NameForm Rs 5127
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesrs 5127, supersede, 1974, designating

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Office of the New York State Comptroller New York State and Local Retirement System

Employees’ Retirement System

Police and Fire Retirement System

110 State Street, Albany, New York 12244-0001

RECEIVED

Designation of Beneficiary With Contingent Beneficiaries

For Active Members Only (NOT RETIREES)

RS 5127

(Rev.11/11)

THIS FORM MUST BE SIGNED, NOTARIZED AND FILED WITH THE RETIREMENT SYSTEM PRIOR TO YOUR DEATH TO BE EFFECTIVE.

PLEASE PRINT CLEARLY USING CAPITAL LETTERS. USE ONLY BLUE OR BLACK INK. STAY WITHIN BOXES. LEAVE BLANK BOXES BETWEEN WORDS AND NUMBERS AS SHOWN IN THIS EXAMPLE.

S M I

T H

J O H N

F

MEMBER INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

Last 4 Digits of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Registration Number (if known)

Social Security Number* Maiden or Other Name Used

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

–

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month Day

 

 

Year

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Name

 

 

 

 

 

 

 

 

 

 

 

 

 

M.I.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address 1

Street Address 2

City

State

Zip Code

–

Employed By:

Employer Address:

IMPORTANT INFORMATION REGARDING THIS FORM

•฀ If you find this form is not suited to the type of designation you prefer please advise the Retirement System. In the meantime, for your protection and the protection of your beneficiary(ies), you should make an interim designation using this form. If you wish to designate more beneficiaries than this form allows or to designate a Trust, Guardianship or payment under the Uniform Transfers to Minors Act please contact the Retirement System for the appropriate form.

•฀ Attachments to your beneficiary form are unacceptable.

•฀ New beneficiary forms filed will supersede any previous designation. Therefore, if you want to ADD or DELETE a beneficiary, for example a new child, you must include on the new form all beneficiaries you wish to designate.

•฀ The same person or persons cannot be designated as both primary and contingent beneficiaries. We can make payment to a contingent beneficiary(ies) only if ALL primary beneficiary(ies) die before you do.

•฀ If you wish to have your ordinary death benefit distributed through your estate, you should name “my estate” as beneficiary. Your estate can be named as either primary or contingent beneficiary. However, if you name your estate as a primary beneficiary, you may not name any contingent beneficiary.

•฀ This form is for designating beneficiaries to receive ordinary death benefits, if ordinary death benefits become payable on account of your death. You may not designate beneficiaries to receive accidental death benefits. The beneficiaries entitled to receive accidental death benefits are mandated by statute.

Make sure that you:

•฀ Complete all required information. •฀ Sign and date the form.

•฀ Have the form notarized, making sure the notary has entered his or her expiration date.

•฀ Mail your completed form to:

New York State and Local Retirement System

Member & Employer Services

Registration – Mail Drop 5-6

110 State Street

Albany, NY 12244-0001

PERSONAL PRIVACY PROTECTION LAW

In accordance with the Personal Privacy Law you are hereby advised that pursuant to the Retirement and Social Security Law, the Retirement System is required to maintain records. The records are necessary to determine eligibility for and to calculate benefits. Failure to provide information may result in the failure to pay benefits. The System may provide certain information to participating employers. The official responsible for maintaining these records is the Director of Member & Employer Services, New York State and Local Retirement Systems, Albany, NY 12244; telephone number 518-474-3524.

*SOCIAL SECURITY DISCLOSURE REQUIREMENT

In accordance with the Federal Privacy Act of 1974, you are hereby advised that disclosure of the Social Security Account Number is mandatory pursuant to sections 11, 31, 34 and 334 of the Retirement and Social Security Law. The number will be used in identifying retirement records and in the administration of the Retirement System.

Please go to the reverse side of this form to designate beneficiaries, sign and date the form, and have the form notarized.

RS 5127 (front)

Do not alter this form or make stipulations. The use of correction fluid or other alterations on this form will render the designation invalid.

To the Comptroller of the State of New York.

Designation of Primary Beneficiary(ies). I hereby name the following beneficiary(ies) to receive any ordinary death benefit payable on my behalf. If I have named more than one beneficiary, it is my intention that those living at the time of my death should share equally any benefit payable. I reserve the right to change this designation at any time.

PRIMARY

 

 

 

 

 

 

 

 

 

Date of Birth

 

 

 

 

Last Name

 

 

 

 

First Name

 

M.I.

Month

Day

 

Year

1

 Male

Relationship (Fill in one circle)

 

 

 

 

 

 

 

 

 

 Female

 Spouse

Parent

Child

Other

Address:

Street

Apt. or Unit#

City

 

State

Zip Code

 

Last Name

 

 

 

 

First Name

 

M.I.

Month

Day

 

Year

2

 Male

Relationship (Fill in one circle)

 

 

 

 

 

 

 

 

 

 Female

 Spouse

Parent

Child

Other

Address:

Street

Apt. or Unit#

City

 

State

Zip Code

 

Last Name

 

 

 

 

First Name

 

M.I.

Month

Day

 

Year

3

 Male

Relationship (Fill in one circle)

 

 

 

 

 

 

 

 

 

 Female

 Spouse

Parent

Child

Other

Address:

Street

Apt. or Unit#

City

 

State

Zip Code

 

Last Name

 

 

 

 

First Name

 

M.I.

Month

Day

 

Year

4

 Male

Relationship (Fill in one circle)

 

 

 

 

 

 

 

 

 

 Female

 Spouse

Parent

Child

Other

Address:

Street

Apt. or Unit#

City

 

State

Zip Code

Designation of Contingent Beneficiary(ies). If all of the designated primary beneficiaries die before I do, any ordinary death benefit payable on my behalf shall be paid to the following. If I have named more than one beneficiary, it is my intention that those living at the time of my death should share equally any benefit payable. Furthermore, if I out-live these beneficiaries, any benefit payable should be paid to my estate or any other beneficiary I name thereafter. I reserve the right to change this designation at any time.

CONTINGENT

 

 

 

 

 

 

 

 

 

Date of Birth

 

 

 

 

Last Name

 

 

 

 

First Name

 

M.I.

Month

Day

 

Year

1

 Male

Relationship (Fill in one circle)

 

 

 

 

 

 

 

 

 

 Female

 Spouse

Parent

Child

Other

Address:

Street

Apt. or Unit#

City

 

State

Zip Code

 

Last Name

 

 

 

 

First Name

 

M.I.

Month

Day

 

Year

2

 Male

Relationship (Fill in one circle)

 

 

 

 

 

 

 

 

 

 Female

 Spouse

Parent

Child

Other

Address:

Street

Apt. or Unit#

City

 

State

Zip Code

 

Last Name

 

 

 

 

First Name

 

M.I.

Month

Day

 

Year

3

 Male

Relationship (Fill in one circle)

 

 

 

 

 

 

 

 

 

 Female

 Spouse

Parent

Child

Other

Address:

Street

Apt. or Unit#

City

 

State

Zip Code

 

Last Name

 

 

 

 

First Name

 

M.I.

Month

Day

 

Year

4

 Male

Relationship (Fill in one circle)

 

 

 

 

 

 

 

 

 

 Female

 Spouse

Parent

Child

Other

Address:

Street

Apt. or Unit#

City

 

State

Zip Code

This form must be signed and notarized in order to be valid

Member’s Signature

Date

Acknowledgement To Be Completed by a Notary Public

State of _____________________________________________ County of ____________________________________________

On the ______ day of _________________ in the year _________ before me, the undersigned, personally appeared ____________________________, personally

known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument.

RS 5127 (Rev. 11/11)

NOTARY PUBLIC (Please sign and affix stamp)

reverse

 

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2. The third step is usually to submit these blanks: Last Name, First Name, Date of Birth, Month, Day, Year, Y R A M R P, Male Female, Relationship Fill in one circle, Spouse Parent, Child Other, Address Street, Apt or Unit, City, and State.

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