Fillable Printable Authorization to Release Death Beneficiary Information Form - Pennsylvania
Fillable Printable Authorization to Release Death Beneficiary Information Form - Pennsylvania
Authorization to Release Death Beneficiary Information Form - Pennsylvania
COMMONWEALTH OF PENNSYLVANIA
STATE EMPLOYEES' RETIREMENT SYSTEM
30 N 3RD STREET
SUITE 150
HARRISBURG, PA 17101-1716
TOLLFREE: 1-800-633-5461
www.sers.state.pa.us
BENEFICIARY INFORMATION
AUTHORIZATION TO RELEASE DEATH
1
SS#
I,
, hereby authorize the Pennsylvania State
Member's Printed Name
Employees' Retirement System ("SERS") to release the names of my death beneficiaries and guardians of minor
beneficiaries, if any, to the following individuals:
Name
Relationship to Member
I hereby revoke any authorization to release death beneficiary information previously provided to SERS,
whether given orally or in writing, unless such authorization was provided pursuant to an order of court. I
understand that the revocation herein does not revoke any Power of Attorney previously provided to SERS. I
understand that an authorization above to release such information to my spouse will remain valid until I
revoke it, even if my spouse and I divorce. A photocopy or faxed copy of this Authorization to Release Death
Beneficiary Information shall have the same force and effect as the original.
Signature
Date
SERS-405b (Rev. 12/2004)
