Change of Beneficiary Form

CHANGE OF BENEFICIARY FORM
To be filed with the board upon change of beneficiary in accordance with G.L. c. 32, S 11(2)(c).

To the WATERTOWN Retirement Board:

I, , Social Security # request that the Retirement Board named above change the beneficiary designated on my New Member Enrollment Form (or if subsequent to retirement, the Choice of Retirement Option Form) and pay any sum referred to in said section 11(2)(c) due at my death to the following beneficiary or beneficiaries in the proportions designated.

*PRIMARY BENEFICIARY(IES):*	Relationship To Member	Date of Birth		% of Benefit
NAME
ADDRESS
NAME
ADDRESS
CONTINGENT BENEFICIARY(IES): In the event of the death of my primary beneficiary(ies):	Relationship To Member	Date of Birth	% of Benefit
NAME
ADDRESS
NAME
ADDRESS

The right to change any beneficiary is reserved. Changes may be made by filing a new change of beneficiary form. This Form may also be used, subsequent to the member’s retirement, to change the Option (B) beneficiary designated on the member’s Choice of Retirement Option Form. Election of a beneficiary, under G.L. c.32, s.12 (2)C may not be made on this form. Such election may be made only on the Choice of Retirement Option Form.

TYPES OF PAYMENTS COVERED UNDER SECTION 11(2)(C) INCLUDE:
1.The payment of the accumulated total deductions credit to your account in the annuity savings fund at the date of your death should it occur prior to your retirement;*
2.The payment of any cash refund due at your death if your retirement election was Option (B)
3.The payment of any prorated monthly amount due at your death if you elected Option (A) or (B)

*NOTE: In the case of a member’s death prior to retirement where such member is survived by an eligible beneficiary appointed under Option (D) of subdivision (2) of section 12 or if the deceased member is survived by a person eligible to receive the allowance provided for in section 12B, or is survived by a child eligible to receive the allowance provided for in section 12B, no payment of the amount of accumulated total deductions credited to the surviving spouse or person acting for such child elects, in lieu of receiving allowances provided for in section 12B, to have payment made of the amount due under section 11(2).

Member’s Signature: ____________________________________________ DATE: ______________
Member’s Address:

Witness’ Signature: ______________________________________________DATE:_____________

Witness’ Address:

IMPORTANT: THE WITNESS SIGNING THIS FORM MUST BE SOMEONE OTHER THAN THE BENEFICIARY. A CHANGE OF BENEFICIARY FORM WITH CORRECTIONS OR ERASURES WILL NOT BE ACCEPTED