Fillable Printable Form Beneficiary Designation Form

Form Beneficiary Designation Form

Beneciary Designation

This form allows members, retirees, survivors,

legal-order payees and those separated from

service to name or update their benet recipients.

Send completed form to:

Department of Retirement Systems

PO Box 48380 ꔷ Olympia, WA 98504-8380

www.drs.wa.gov

ꔷ 800.547.6657

360.664.7000 ꔷ TTY: 711

DRS MS 100 3/17

*DRSMS100*

Personal Information

Name (Last, First, Middle)Social Security Number

Mailing AddressCityStateZIP

Date of Birth (mm/dd/yyyy)Phone NumberAlternate Phone Number

Email Address

My Status (Check All That Apply)

c Member (active or inactive): I am a DRS member who contributes (active) or has contributed to (inactive) a DRS retirement system

and/or participates in DCP.

c Retiree: I am a DRS member who contributed to a retirement system and is now collecting a retirement benet.

c Survivor: I am receiving a benet from a deceased DRS member’s or retiree’s account.

c Legal-Order Payee:

I have been awarded a portion of a DRS retirement benet.

Are you receiving money from someone else’s account?

c Yes (Provide Name and Social Security Number Below) c No

Account Holder’s Name (If Different from Above)Social Security Number (If Different from Above)

Retirement System and/or Program

c Apply to All My Retirement Plans/Programs c Washington State Patrol Retirement System (WSPRS)

c Public Employees’ Retirement System (PERS) c Law Enforcement Ofcers’ and Fire Fighters’ Retirement System (LEOFF)

c Teachers’ Retirement System (TRS) c Public Safety Employees’ Retirement System (PSERS)

c School Employees’ Retirement System (SERS) c Judicial Retirement System (JRS)

c Deferred Compensation Program (DCP) c Judges’ Retirement Fund (JRF)

Important Information

Members can make this change quickly online at

www.drs.wa.gov/oaa

. Any current primary beneciaries you’ve

named will appear. You can then edit them or even copy them to another retirement system or program. If

you use a paper form to submit your choices, only your primary beneciaries will appear online until you add

contingent beneciaries in your online account. If you decide to ll out this paper form, please return it to DRS,

not your employer. If you make a mistake, please correct it and initial beside the correction.

Please complete the other side of this form as well.

Your Social Security number is needed so DRS can report to the IRS any funds paid to you. DRS will not disclose your

Social Security number unless required to do so by law. See IRC sections 6041(a) and 6109.

Clear Form

Signature Required

Pay any funds related to my account to my primary beneciary(ies) in the percentage(s) I chose or as required by law. If any

beneciaries precede me in death, share their percentages equally among the remaining primary beneciaries. If no primary

beneciaries survive me, send any funds to my contingent beneciaries. All the information I have entered is true and complete.

These changes replace any previous beneciary choices I have made.

SignatureDate

Beneciary Designation

Primary _____ %

Name (Last, First) or Full Name of EntityMailing Address

RelationshipSocial Security NumberDate of BirthCityStateZIP

c Primary _____ %

c Contingent _____ %

Name (Last, First) or Full Name of EntityMailing Address

RelationshipSocial Security NumberDate of BirthCityStateZIP

c Primary _____ %

c Contingent _____ %

Name (Last, First) or Full Name of EntityMailing Address

RelationshipSocial Security NumberDate of BirthCityStateZIP

c Primary _____ %

c Contingent _____ %

Name (Last, First) or Full Name of EntityMailing Address

RelationshipSocial Security NumberDate of BirthCityStateZIP

Instructions

You must name at least one primary beneciary. Do not name yourself. If you pick more than one primary

beneciary or more than one contingent beneciary, the total percentage(s) for each category must add up to

100%. Use whole numbers (for example, 50% and 50% or 66% and 34%).

If you have more than four beneciaries, attach a separate sheet with the same information as below; then sign

and date it. Alternatively, you can update your beneciary information online.

If you die in the line of duty, your beneciary(ies) could be entitled to a one-time, duty-related death benet.

The same people you name below on this form will automatically be added as your beneciary(ies) for this

benet. If you want to name different people or put in different percentages, you can make those changes in

your online account at

www.drs.wa.gov/oaa

Important Denitions

Primary beneciary: A person or entity (for example, an estate, trust, charitable organization, etc.) you

choose to receive your money. After your death, we will pay all primary beneciaries either equally or in the

percentages you chose or as required by law. The total designation for your primary beneciary selection(s)

must equal 100%.

Contingent beneciary: A person or entity you choose to receive your money if both you and all your primary

beneciaries die. The total designation for your contingent beneciary selection(s) must equal 100%.