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APPLICATION FOR CHANGE OF BENEFICIARY ­ ACTIVE MEMBER
(Annuity Savings Account or Rollover Account)
State Form 1856 (R5 / 8-08)

* PRIVACY NOTICE All Social Security Numbers are requested by this agency in accordance with the requirements of the Internal Revenue Code. Disclosure is mandatory; this form will not be processed without the information

INSTRUCTIONS: 1. Please TYPE or PRINT. Use black ink. 2. Complete all information. Remember to put your name and Social Security Number at the top of every page. 3. You must sign at the bottom of page 2 and any additional pages. Each page must be witnessed by someone who is not your beneficiary. 4. Draw a line through any unused beneficiary information boxes. 5. Return the completed form directly to PERF.

You have the right to change your primary and/or contingent beneficiary or beneficiaries at any time prior to distribution of your Annuity Savings Account or Rollover Account. Your beneficiary or beneficiaries can only be changed by filing this form with PERF at the following address: Public Employees' Retirement Fund 143 West Market Street Indianapolis, IN 46204 Fax: (317) 234-5922 This Change of Beneficiary revokes and replaces all previously named beneficiaries. You must list everyone that you wish to name as a beneficiary. In lieu of an individual, you may name a trust or legal entity as a beneficiary. You must furnish PERF with the name, address, and Social Security Number or Tax Identification Number of each beneficiary. If you wish to name additional beneficiaries, you may attach copies of page 2 containing the necessary information. Be certain to initial the box below and indicate the number of additional pages. Each page must be signed and witnessed by someone who is not your beneficiary.

This is for my:

Annuity Savings Account

Rollover Savings Account

APPLICANT INFORMATION
Social Security Number *


First name Address (number and street) Middle initial Last name


City Home telephone number State Other telephone number ZIP code

( )
E-mail address

(

)



Important: If you have attached additional pages of beneficiaries, you must initial the box and indicate the number of additional pages you have attached.

Number of additional pages Initial here

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APPLICATION FOR CHANGE OF BENEFICIARY ­ ACTIVE MEMBER
(Annuity Savings Account or Rollover Account) (continued)
State Form 1856 (R5 / 8-08)

Name of member (last, first, middle initial)

Social Security Number

BENEFICIARY INFORMATION (Attach additional copies of this page if necessary.)
Primary Beneficiary or Beneficiaries
Name of beneficiary (last, first, middle initial) Date of birth(month, day, year) Address (number and street) Social Security Number or tax identification number Relationship to member City State ZIP code


Name of beneficiary (last, first, middle initial) Date of birth(month, day, year) Address (number and street) Social Security Number or tax identification number Relationship to member City State ZIP code


Contingent Beneficiary or Beneficiaries
Name of beneficiary (last, first, middle initial) Date of birth(month, day, year) Address (number and street) Social Security Number or tax identification number Relationship to member City State ZIP code


Name of beneficiary (last, first, middle initial) Date of birth(month, day, year) Address (number and street) Social Security Number or tax identification number Relationship to member City State ZIP code



In accordance with the provisions of Indiana Code § 5-10.2-3, I designate my beneficiary or beneficiaries as shown above. If the primary beneficiary or beneficiaries herein designated survive me, they shall receive the funds, if any, that are payable by the fund to a designated beneficiary. If the primary beneficiary or beneficiaries do not survive me, then the contingent beneficiary or beneficiaries shall receive such funds. If none survive me, then the beneficiary shall be my estate. If no designation is made, any death benefit due would be payable to my estate. I reserve the right to change the primary or contingent beneficiaries at any time prior to distribution of my Annuity Savings Account by filing a Change of Beneficiary form with the Board of Trustees of the Fund. Such a change must be received and accepted by the fund for it to become effective. I understand that this designation of beneficiary supersedes and replaces any prior designation of beneficiary or beneficiaries that may have been made in the course of this or any prior employment in a PERF-covered position with any other employer.
Signature of member Signature of witness Printed name Printed name Date of birth(month, day, year) Date of birth(month, day, year)

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