PERS Beneficiary Nomination

You are required to complete this form.

Member information

• Complete all sections

Membership status

• Check the Member box.

Beneficiary information

• List beneficiaries and complete all of their information. You must choose at least a primary beneficiary. If you choose more than one beneficiary, primary beneficiary(s) must total 100%, secondary beneficiary(s) must total 100% and tertiary beneficiary(s) must total 100%.

Membership retiree authorization

• Print, sign and date.

Spousal waiver

• If you choose not to include your spouse as your 100% primary beneficiary, your spouse will need to complete this section and have it notarized.