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DESIGNATION OF BENEFICIARY
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1.
Step One
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2.
EMPLOYMENT INFORMATION
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3.
DESIGNATION OF BENEFICIARY
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4.
APPLICATION FOR PARTICIPATION SHELBY RETIREMENT SYSTEM - PLAN D
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Step One
Full Name of Husband or Wife:
Spouse's First Name
Spouse's Middle Name
Spouse's Last Name
Date of Husband or Wife's birth:
Date of Husband or Wife's birth:
Date of Husband or Wife's birth:
Date of Marriage:
Date of Marriage:
Date of Marriage:
Give, the names, date and place of birth of your children under 19 years of age.
Name:
Date Of Birth
Date Of Birth
Date Of Birth
Place of Birth
Name:
Date of Birth
Date of Birth
Date of Birth
Place of Birth
Name:
Date of Birth
Date of Birth
Date of Birth
Place of Birth
Name:
Date of Birth
Date of Birth
Date of Birth
Place of Birth
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EMPLOYMENT INFORMATION
Shelby County Occupation
Shelby County Department
3. Date you began present employment with County
3. Date you began present employment with County
Below, list All periods of employment with the County in the last three years. If you are being reemployed and you have previously received a refund of your contributions, you may redeposit those contributions with interest and receive prior vesting credit. Contact the Retirement Office immediately because you only have one (l) year to redeposit those funds.
From
From
To
To
Occupation
Department
From
From
To
To
Occupation
Department
From
From
To
To
Occupation
Department
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DESIGNATION OF BENEFICIARY
As a participant in the Shelby County Retirement System Plan D (the "Plan"), you are required to make contributions to the Plan. If you die before you have earned at least 15 years of Credited Service, your Survivors (other than dependent children) are not entitled to any survivor pension from the Plan. If this is the case, your named beneficiary will receive your contributions back with interest.
This form permits you to name beneficiaries of your vested contributions. If you have been married at least three (3) years at the time of your death, your surviving spouse will automatically be your designated beneficiary unless both you and your spouse elect otherwise on a separate form which must be obtained from the Retirement Office. If you are not married at the time of your death (or have been married fewer than 3 years) and if you fail to name one or more beneficiaries below, your beneficiaries will be the following persons in the following order; (1) spouse of fewer than three years; (2) your children, if any; (3) your parents, if living, or the survivor, (4) your estate.
I certify that I am not currently married or have not been married for at least three (3) years. Accordingly, I hereby designate the following person (or persons) as beneficiary (or beneficiaries) of my vested contributions and interest. If I have named more than one person, all of the persons named will receive an equal share of my vested contributions and interest unless I have specifically provided otherwise below:
Name:
Relationship
Date of Birt
Date of Birt
Percentage
Name:
Relationship
Date of Birth
Date of Birth
Percentage
Name:
Relationship
Date of Birth
Date of Birth
Percentage
Name:
Relationship
Date of Birth
Date of Birth
Percentage
I hereby certify that the answers to the foregoing questions are true and correct to the best of my knowledge, information and belief.
Witness Signature (Staff Employee)
Date
Date
Signature of Employee
Date
Date
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APPLICATION FOR PARTICIPATION SHELBY RETIREMENT SYSTEM - PLAN D
Instructions for completing this form. Read completely and carefully.
In order for this to be a permanent part of your records, this form must be filled out in INK or typewritten. It cannot be accepted if it is filled out in pencil or in any other manner other than ink or typewritten.
Please fill in all blanks and answer all questions. If the blanks or questions do not apply to you, then please show with an answer that they do not apply to you.
This form will be used to determine your status in the Retirement System and in regard to various benefits that you could receive from the Retirement System. For this reason, it is most important that the Board of Administration, who will establish your status, have complete and conect answers in order to correctly determine your status. If you do not know the answers to some of the questions, look at any records that might help you in getting the correct answers.
REMEMBER CORRECT ANSWERS ARE IMPORTANT
in determining your status and benefits in the Retirement System.
All the information in this form is confidential and used by the Board of Administration only in the operation of the Retirement System.
PERSONAL INFORMATION
First Name
Middle
Last Name
Sex
Female
Male
Trans-Female
Trans-Male
Other
Date of Birth
Date of Birth
City Place of Birth
State of Birth
-- Select One --
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Family Information
Marital Status
Married
Divorced
Unmarried
Date of Divorce
Date of Divorce
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