NYCERS Form F501 – Fill Out and Use This PDF

NYCERS USE ONLY	F501

*501*

Designation of Beneficiary(ies)

Post-Retirement Lump-Sum Death Benefit

This application is for those who wish to nominate a beneficiary(ies) to receive a post-retirement lump-sum death benefit. If the designated Primary Beneficiary(ies) predeceases you, the lump-sum payment will be paid to your designated Contingent Beneficiary(ies). If none exists, the lump-sum benefit will be paid to your estate. Should you have any questions, please contact our Call Center at 347-643-3000.

Member Number OR	Pension Number		Last 4 Digits of SSN			Phone Number
						(	)
First Name		M.I.		Last Name
in Care of (if applicable)
Address							Apt. Number
City					State			Zip Code

I understand that at the time of my death after retirement, the lump-sum death benefit will be paid to my surviving designated Primary Beneficiary(ies). If the designated Primary Beneficiary(ies) predeceases me, the lump-sum death benefit will be paid to my designated Contingent Beneficiary(ies). If none exists, the lump-sum death benefit will be paid to my estate.

I, the undersigned, nominate as my beneficiary(ies) for the lump-sum death benefit payable on my death after retirement:

01/08/13

Page 1 of 2

NYCERS USE ONLY	F501

Member Number OR	Pension Number	Last 4 Digits of SSN

If the foregoing Primary beneficiary(ies) should predecease me, I hereby nominate the following as Contingent beneficiary(ies) for the above Post-Retirement Lump-Sum Death Benefit.

I am nominating my Estate as my beneficiary for my post-retirement lump-sum death benefit. I understand that in order for this selection to be valid I may not write in any other beneficiary's name on this form, and I have, in fact, left all other designation of beneficiary sections on this form blank.

Should I survive all designated beneficiaries, the post-retirement lump-sum death benefit shall be paid to my Estate or to such other beneficiary or beneficiaries as I shall hereafter nominate by filing another designation of beneficiary form with NYCERS.

Signature of Member	Date

(Witnesses necessary only if mark is	Witnessed by (1):
used for signature)
	Witnessed by (2):
This form must be acknowledged before a Notary Public or Commissioner of Deeds

State of

County of

On this

day of

2 0

, personally appeared

before me the above named,

, to me known, and known to

me to be the individual described in and who executed the foregoing instrument, and he or she acknowledged to me that he or she executed the same, and that the statements contained therein are true.

Signature of Notary Public or Commissioner of Deeds

Official Title

Expiration Date of Commission

Sign this form and have it notarized, THIS PAGE

01/08/13

Page 2 of 2