Survivor Beneficiary Designation Form

Survivor Beneficiary Designation Form

Survivor Beneficiary Designation Form Public Employees’ Retirement System of Nevada 693 W. Nye Lane, Carson City, NV 89703 - (775) 687-4200 - Fax (77...

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Survivor Beneficiary Designation Form Public Employees’ Retirement System of Nevada

693 W. Nye Lane, Carson City, NV 89703 - (775) 687-4200 - Fax (775) 687-5131 7455 W. Washington Ave., Suite 150, Las Vegas, NV 89128 - (702) 486-3900 - Fax (702) 304-0697 5820 S. Eastern Ave., Suite 220, Las Vegas, NV 89119 - (702) 486-3900 - Fax (702) 678-6934 Toll Free: (866) 473-7768 www.nvpers.org

Member Information

Name Change  Yes

 No

If Yes, Former Name: ____________________________

Name: ______________________________________________________SSN: __________________________ Birth Date: _______________M F Address: _____________________________________________________________City, State, Zip: ________________________________________ Home Phone: ______________________________Work Phone: __________________________________ Employer: __________________________ Married or have a registered domestic partner?

 Yes

 No

Family Beneficiary Information A spouse or registered domestic partner is the member’s primary beneficiary and will be considered first to receive any lifetime benefit available in the event of the member’s death prior to retirement. If a monthly benefit is not available, the spouse or registered domestic partner may be eligible to receive a one-time, lump-sum payment of any existing member contributions in the System. Children under age 18 may be eligible to receive a limited benefit.

Name of Spouse or Registered Domestic Partner: _________________________________SSN: ________________Birth Date: _____________M F List all unmarried children (biological or legally adopted) under age 18. (Attach separate sheet if necessary.) Name: _________________________________________________SSN: __________________________Birth Date: _____________________M F Name: _________________________________________________SSN: __________________________Birth Date: _____________________M F Name: _________________________________________________SSN: __________________________Birth Date: _____________________M F

Survivor Beneficiary Designation All PERS members should list one person as the Survivor Beneficiary in this area of the form (not a spouse or

registered domestic partner, trust or charitable organization) to receive a lifetime benefit that may be payable in the event of an unmarried member’s death or a member and spouse’s/registered domestic partner’s simultaneous death prior to retirement. Additional Payees may also be designated to split the payment with the Survivor Beneficiary by percentage. Monthly payments to Additional Payees cease upon the death of the designated Survivor Beneficiary. ___________ Benefit Survivor Beneficiary: (If you do not wish to provide a lifetime benefit for a Survivor Beneficiary/Additional Payees, indicate NONE.) Percentage Name: _______________________________________________SSN:____________________ Birth Date: _________________ M F Address: ______________________________________________City, State, Zip: ____________________________________________

________%

Additional Payees: (Attach separate sheet, if necessary) Name: _______________________________________________SSN:____________________ Birth Date: _________________ M F Address: ______________________________________________City, State, Zip: ____________________________________________

________%

Name: _______________________________________________SSN:____________________ Birth Date: _________________ M F Address: ______________________________________________City, State, Zip: ____________________________________________

________%

Name: _______________________________________________SSN:____________________ Birth Date: _________________ M F Address: ______________________________________________City, State, Zip: ____________________________________________ TOTAL PERCENTAGES FOR SURVIVOR BENEFICIARY + ALL ADDITIONAL PAYEES = Survivor Beneficiary & Additional Payee percentages must be whole numbers and total 100% when added together

________% _ Total %

Tertiary Beneficiary Designation The tertiary beneficiary may be eligible to receive a one-time, lump-sum payment of any refundable employee

contributions in the System if no one else listed above is eligible. If more than one person is listed, the payment will be split equally unless otherwise stated by the member. Charitable organizations and trusts may be designated here. Attach a separate sheet if necessary. Name: _____________________________________________________SSN:_______________________Birth Date: __________________ M F Address: _______________________________________________________City, State, Zip: _____________________________________________ I understand that the information designated on this form supersedes all prior beneficiary designations that I have submitted on other forms, and that this information only affects records with the Public Employees’ Retirement System. Member Signature: __________________________________________Date: _______________________ Rev. 2/11

For PERS Use - Date Received

Survivor Benefits If a member dies prior to retirement, eligible survivors are entitled to a monthly survivor benefit. Pursuant to NRS 286.671, eligible survivors are the member’s spouse or Survivor Beneficiary and Additional Payees. In addition, dependent children under the age of 18 at the time of the member’s death would also be eligible for a benefit. In order for the Survivor Beneficiary and Additional Payees to receive benefits, the member must be unmarried at the time of death. To qualify for survivor benefits, the member must have: 1. 2. 3.

Two years of service in the two and one-half years immediately preceding the member’s death; Ten or more years of accredited service; or Died as a result of an occupational disease or as a result of an accident arising out of or in the course of employment, regardless of service credit.

The calculation of benefits for the spouse or the Survivor Beneficiary and Additional Payees is based on the number of years of service credit the member had at the time of death. If the member had less than 10 years of service credit, the benefit would be $450.00 paid to the spouse or split between the Survivor Beneficiary and the Additional Payees based on the designated percentage. If the member had more than 10 years of service credit but less than 15 years, the benefit would be paid under Option 3, which is calculated based on the member’s age at the time of death, the spouse’s or Survivor Beneficiary’s age, member’s service credit, and average compensation. A flat rate monthly benefit of $450.00 could be substituted for the Option 3 benefit, depending on which is greater. If the member had more than 15 years of service credit or was fully eligible to retire, the benefit would be paid under Option 2, which is calculated based on the member’s age at the time of death, the spouse’s or Survivor Beneficiary’s age, member’s service credit, and average compensation. A flat rate monthly benefit of $450.00 could be substituted for the Option 2 benefit, depending on which is greater. Dependent children under the age of 18 at the time of the member’s death, who were the issue of or legally adopted children of the member, are entitled to a monthly benefit of $400.00 per month until the child reaches age 18. Once the child reaches age 18, he/she must be a continuous full-time student, to receive benefits until age 23. Benefits cease upon death of the Survivor Beneficiary. Therefore, if the System was paying benefits to a Survivor Beneficiary and Additional Payees, when the Survivor Beneficiary dies, payments to the Additional Payees would cease as well. If an Additional Payee dies, the benefit amount would be redistributed among the remaining payees. The designation of the Survivor Beneficiary and the Additional Payees must be made on the PERS’ form entitled Survivor Beneficiary Designation. Your named Survivor Beneficiary and Additional Payees would receive payment based on the percentages you designated for the lifetime of the Survivor Beneficiary. The form must be properly completed and be submitted or postmarked with a date prior to the member’s death. In the event the member fails to meet eligibility requirements for survivor benefits prior to death, a lumpsum refund of any employee contributions would be paid to the member’s spouse. If no spouse exists the refund would be paid to the listed Survivor Beneficiary/Additional Payees. If there are no listed Survivor Beneficiary/Additional Payees the refund would be paid to the listed Tertiary Beneficiary/ies. If there are no listed Tertiary Beneficiary/ies the refund would be paid to the member’s estate. If there is no estate, the refund would be paid to the member’s heirs. If you have additional questions, please contact our Counseling Services Division at (775) 687-4200, tollfree 1-866-473-7768 or contact our Las Vegas office at (702) 486-3900.