GENESEE COUNTY EMPLOYEES’ RETIREMENT SYSTEM
 

CHANGE OF NOMINATION OF BENEFICIARY FORM

FOR ACCUMULATED CONTRIBUTIONS

(LESS THAN 15 YEARS OR LESS THAN 10 YEARS ON OR AFTER AGE 60)

 

Member’s Name:

 

Prior Name (if applicable):

(print)

Member’s Social Security Number:

 

Department Employed:

 

 

 

 
 

I hereby revoke and cancel my previous nomination of beneficiary and direct the Genesee County Employees’ Retirement System to pay the accumulated contributions standing to my credit in the event of my death when no retirement allowance is otherwise payable (death prior to age 60 with less than 15 years of Credited Service or death on or after age 60 with less than 10 Years of Credited Service), to:


Primary Beneficiary’s Full Name:

(must be a natural person and must survive me)

 

Primary Beneficiary’s Relationship to Member:

 

Primary Beneficiary’s Date of Birth:

 

Primary Beneficiary’s Address:

 


 

 


 

If my Primary Beneficiary dies before me, pay to:


Secondary Beneficiary’s Full Name:

(must be a natural person and must survive me)

 

Secondary Beneficiary’s Relationship to Member:

 

Secondary Beneficiary’s Date of Birth:

 

Secondary Beneficiary’s Address:

 


 

 


 

If both my Primary Beneficiary and my Secondary Beneficiary die before me, pay to my legal representative.


 

I understand that this change of nomination pertains only to my accumulated contributions and  does not affect a change of beneficiary for my retirement pension benefits, if applicable.

Member’s Signature:

 

Date:

 

Witnessed by: