BENEFICIARY DESIGNATION FORM Active & Inactive Members

Name: DERP ID:

Social Security Number: City ID:

Home Address: Street Address, City, State, Zip Code Telephone Number: Email Address:

WHO IS YOUR BENEFICIARY? It is very important to designate a beneficiary for your DERP account. Active and inactive members are able to name both a primary beneficiary, as well as a contingent beneficiary. The purpose of having a beneficiary on file is to ensure your DERP benefit is paid to someone in the event that you unexpectedly pass away prior to collecting your DERP benefit. There are specific rules for who can be named as a beneficiary:

If you are married, your spouse must be your primary beneficiary, unless he/she signs a waiver.

If you are not married, but have children under the age of 21, you must name all of your children under age 21 as your primary beneficiaries.

If you are not married and do not have children under the age of 21, you may name any one individual person to be your primary beneficiary.

You may not list an estate, trust, or charity as either your primary or contingent beneficiary.

You may only name one contingent beneficiary.

PRIMARY BENEFICIARY

Primary Beneficiary’s Name and Address Social Security Number Date of Birth Relationship

Name: Address:

*NOTE: If you are naming multiple children under age 21 as your primary beneficiaries, please attach a separate sheet and include all of the information shown above for each child.

CONTINGENT BENEFICIARY

Contingent Beneficiary’s Name and Address Social Security Number Date of Birth Relationship

Name: Address:

*NOTE: A contingent beneficiary will only receive a benefit if there is not a surviving primary beneficiary. Employee Signature: Date:

This form must be notarized. State of )

City of )

County of )

The foregoing instrument was signed and acknowledged before me this day of , . WITNESS my hand and official seal. Notary Public My commission expires

Denver Employees Retirement Plan 777 Pearl St, Denver, CO 80203 Ph: (303) 839-5419 Fx: (303) 839-9525 mbrsvs@derp.org www.myderp.org www.derp.org