GERS_Election_of_Optional_Benefits
ELECTION OF OPTIONAL BENEFITS (Please print all information on document.) Date: ____________________________________ Employee No.: _____________________________ Social Security No.: _________________________ Election by Married Member: I, _________________________________________________________________, do hereby elect a lesser service retirement annuity, with the provision that my beneficiary receive an annuity as provided in the law governing Optional Benefits of the Employees Retirement System; payment to my beneficiary to begin upon my death. Election by Unmarried Member: I, ________________________________________________________________, do hereby elect a lesser service retirement annuity for the designated beneficiary named below. Designation of Beneficiary: The name of my beneficiary under the election made herein is ______________________________________ who is related to me as _____________________________, (SSN) __________________________________, and whose date and place of birth is: (Date) _______–________–___________ (Place of Birth) ______________________ . …
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ELECTION OF OPTIONAL BENEFITS (Please print all information on document.) Date: ____________________________________ Employee No.: _____________________________ Social Security No.: _________________________ Election by Married Member: I, _________________________________________________________________, do hereby elect a lesser service retirement annuity, with the provision that my beneficiary receive an annuity as provided in the law governing Optional Benefits of the Employees Retirement System; payment to my beneficiary to begin upon my death. Election by Unmarried Member: I, ________________________________________________________________, do hereby elect a lesser service retirement annuity for the designated beneficiary named below. Designation of Beneficiary: The name of my beneficiary under the election made herein is ______________________________________ who is related to me as _____________________________, (SSN) __________________________________, and whose date and place of birth is: (Date) _______–________–___________ (Place of Birth) ______________________ . mm dd yyyy I hereby certify that the information stated above is correct and if any error has been made, I agree that the amount payable by the Employees Retirement System may be adjusted to the amounts which would have been payable had no error been made herein. I also understand that I cannot change this option once my retirement becomes final. My retirement becomes final when any retirement benefit payment is cashed or deposited. I hereby elect the "Full Option Benefit" at a semi-monthly cost of $ ____________________________________ . I hereby elect the "Half Option Benefit" at a semi-monthly cost of $ ____________________________________ . In event of separation, death, etc., Optional Benefits cannot be revoked. ___________________ (Please initial) Mailing Address of Beneficiary: _________________________________________________ (Signature of Member) ____________________________________ _________________________________________________ (Signature of Spouse) ____________________________________ _________________________________________________ (Signature of Analyst) Territory of the U.S. Virgin Islands } District of } ss: On this ___________day of________________________ , before me personally appeared __________________________________, known to be the individual whose named is subscribed in the foregoing instrument and acknowledge that ______________________ executed the same as __________________________ free and voluntary act. ______________________________________________________ Notary Public Commission Expires _____________________________________ GERS-BEN106 REV 06 GOVERNMENT EMPLOYEES RETIREMENT SYSTEM 3438 Kronprindsens Gade, GERS Complex - STE 1, St. Thomas, VI 00802-5750 • (340) 776-7703 • Fax (340) 776-4499 3005 Orange Grove, Lot #5, Christiansted, St. Croix, VI 00820-4313 • (340) 773-5480 • Fax (340) 773-5497