GERS_Request_for_Change_of_Beneficiary
REQUEST FOR CHANGE OF BENEFICIARY Active Retiree Employee No. __________________________ Social Security No. __________–________–______________ Telephone No. __________________________ In accordance with the provision of the law governing the Employees Retirement System of the Government of the Virgin Islands, I, ____________________________________________________________________________________ , designate the following as my beneficiary or beneficiaries in the event of my death: (1) ______________________________________ ________________________ ___________________________ ________________ (Print Name in full) (Beneficiary's date of birth) (Beneficiary's SSN) (Relationship) whose address is: ____________________________________________________________________________________________________________ (2) ______________________________________ ________________________ ___________________________ ________________ (Print Name in full) (Beneficiary's date of birth) (Beneficiary's SSN) (Relationship) whose address is: ______________________________________________________________________ …
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REQUEST FOR CHANGE OF BENEFICIARY Active Retiree Employee No. __________________________ Social Security No. __________–________–______________ Telephone No. __________________________ In accordance with the provision of the law governing the Employees Retirement System of the Government of the Virgin Islands, I, ____________________________________________________________________________________ , designate the following as my beneficiary or beneficiaries in the event of my death: (1) ______________________________________ ________________________ ___________________________ ________________ (Print Name in full) (Beneficiary's date of birth) (Beneficiary's SSN) (Relationship) whose address is: ____________________________________________________________________________________________________________ (2) ______________________________________ ________________________ ___________________________ ________________ (Print Name in full) (Beneficiary's date of birth) (Beneficiary's SSN) (Relationship) whose address is: ____________________________________________________________________________________________________________ (3) ______________________________________ ________________________ ___________________________ ________________ (Print Name in full) (Beneficiary's date of birth) (Beneficiary's SSN) (Relationship) whose address is: ____________________________________________________________________________________________________________ (4) ______________________________________ ________________________ ___________________________ ________________ (Print Name in full) (Beneficiary's date of birth) (Beneficiary's SSN) (Relationship) whose address is: ____________________________________________________________________________________________________________ In the event the foregoing named person(s) do not survive me, my beneficiary shall be: (1) ______________________________________ ________________________ ___________________________ ________________ (Print Name in full) (Beneficiary's date of birth) (Beneficiary's SSN) (Relationship) whose address is: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ If more than one beneficiary is named, the benefit is to be paid equally or on the survivor basis. Any prior designation of beneficiary filed by me is hereby revoked. If the beneficiary or beneficiaries herein nominated shall not survive me and no other written nomination shall have been filed by me with the System, then the beneficiary shall be in the order named: (a) my spouse; (b) my children and descendants thereof by representation; or (c) my parents. The system is hereby requested and directed to make this designation a part of my Membership Record. Continued on the reverse side GERS-BEN102 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 I reserve the right to change my beneficiary at any time by filing with the Board of Trustees of the Employees Retirement System of the Government of the Virgin Islands, written notice of such change, duly acknowledged before a Notary Public. _________________________________________________________________ ________________________________________________________________ Signature of Member Address ________________________________________________________________ City, State, Zip 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-BEN102 REV 06