Nomination of Elective Beneficiary for Ordinary Death Benefits Form

(15 Years or 10 Years on or after Age 60 Death Benefit)

I understand that pursuant to the provisions of Section 35 of the Retirement Ordinance that if I have at least 15 years of credited service or at least 10 years of credited service and have attained 60 years of age, that I may at any time prior to retirement elect Option A provided in Section 27 of the Retirement Ordinance and nominate a natural person as beneficiary.  I further understand that I may revoke this election of Option A and nomination of a beneficiary at any time prior to my retirement and may, if I so desire, complete another Option A election and nominate another natural person as beneficiary.  I understand that the completion of this form makes any and all previous elections null and void.  I understand that no benefits shall be paid under this election if my death is determined to be in the line of duty, pursuant to the provisions of Section 34 of the Retirement Ordinance.

Knowing these facts, I hereby make the following nomination of beneficiary pursuant to the provisions of Section 35 of the Retirement Ordinance.

Beneficiary’s Full Name:

(must be a natural person and must survive me)

Beneficiary’s Relationship to Member:

Beneficiary’s Date of Birth:

Beneficiary’s Address:

Member’s Name:
Member’s Social Security Number:	(print)
Member’s Signature:
Date:

Subscribed to and sworn to before me, a Notary Public of
County, State of		, this	day of		, 20
Signature:				NOTARY PUBLIC
	My Commission Expires: