Form Drs Ms 100 (Rev 8/10) - Member/retiree Beneficiary Designation Form
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3MeMbeR/RetIRee benefIcIaRy DesIgnatIon
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PO Box 48380 Olympia, WA 98504-8380
Clear Form
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Toll Free: 1-800-547-6657
Olympia Area: 360-664-7000
TTY: 360-586-5450
Important:
Please read instructions carefully before completing this form. Return form to DRS, not to your employer.
check one:
c
Public Employees’
c
School Employees’ (non-teachers)
c
State Patrol
c
Judicial
c
Teachers’
c
Law Enforcement Officers’ & Fire Fighters’
c
Public Safety Employees’
Member/Retiree Information
Name (Last, First, Middle)
Social Security Number
Mailing Address
City
State
ZIP
Daytime Phone Number
E-mail Address
(
)
beneficiary Designation* -
You must designate at least one primary beneficiary; do not designate yourself. If you
make a mistake, initial next to your actual designation.
Designation
Beneficiary Information
Relationship
Full Name of Person, Estate, Trust or Organization
Mailing Address
Must check one
c
Primary
Social Security Number
Date of Birth
City
State
ZIP
Contingent
c
Full Name of Person, Estate, Trust or Organization
Mailing Address
Must check one
c
Primary
Social Security Number
Date of Birth
City
State
ZIP
Contingent
c
Full Name of Person, Estate, Trust or Organization
Mailing Address
Must check one
c
Primary
Social Security Number
Date of Birth
City
State
ZIP
Contingent
c
Full Name of Person, Estate, Trust or Organization
Mailing Address
Must check one
c
Primary
Social Security Number
Date of Birth
City
State
ZIP
Contingent
c
*If you are naming more than four beneficiaries please attach a separate sheet that is signed, dated and witnessed.
*DRSMS100*
DRS MS 100 (R 8/10)
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Parent category: Legal