Form Drs Ms 100 (Rev 2/13) - Member/retiree/participant Beneficiary Designation Form
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MEMBER/RETIREE/PARTICIPANT
BENEFICIARY DESIGNATION
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PO Box 48380 Olympia, WA 98504-8380
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Toll Free: 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 All
DCP
Judicial
c
c
c
Law Enforcement Officers’ & Fire Fighters’
c
Public Employees’
That Apply:
Teachers’
State Patrol
School Employees’ (non-teachers)
Public Safety Employees’
c
c
c
c
Member/Retiree/Participant Information
Name (Last, First, Middle)
Social Security Number
Mailing Address
City
State
ZIP
Phone Number
Alternate Phone Number
Email 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. If you select more than one primary beneficiary or more than one
contingent beneficiary, the total percentage(s) for each category must add up to 100%. Use whole numbers (for example,
50% and 50%, or 66% and 34%).
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
c
Contingent
Percentage ____%
Full Name of Person, Estate, Trust or Organization
Mailing Address
Must check one
c
Primary
Social Security Number
Date of Birth
City
State
ZIP
c
Contingent
Percentage ____%
Full Name of Person, Estate, Trust or Organization
Mailing Address
Must check one
c
Primary
Social Security Number
Date of Birth
City
State
ZIP
c
Contingent
Percentage ____%
Full Name of Person, Estate, Trust or Organization
Mailing Address
Must check one
c
Primary
Social Security Number
Date of Birth
City
State
ZIP
c
Contingent
Percentage ____%
*If you are naming more than four beneficiaries please attach a separate sheet that is signed, dated and witnessed.
*DRSMS100*
DRS MS 100 (R 2/13)
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