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Option D Beneficiary Selection Form

(If Member Dies Before Retirement)

Last Revision: May 2016

BOSTON RETIREMENT SYSTEM Tel: 617-635-4311

Boston City Hall, Room 816 Fax: 617-635-4318

Boston, MA 02201 Website: cityofboston.gov/retirement

who has not remarried, child, father, mother, sister or brother of the member.

 Your selection on this form may be superseded by an eligible spouse under the provisions of G.L. c. 32,

§ 12(2)(d) if you die before retirement.

 Should you nominate a person for an Option D benefit, they are ineligible for a lump sum benefit under

§ 11(2).

 You may update or change this beneficiary selection at any time.

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Option D Beneficiary Selection Form

I, (Print Name): , hereby nominate the beneficiary* listed below to

receive from the Boston Retirement System, pursuant to G.L c. 32, § 12(2)(d), a benefit equal to the Option C

retirement allowance, which would otherwise have been payable to me, in the event that I die before being

retired. I understand that I may change my beneficiary designation at any time prior to my retirement and that

upon my retirement this form becomes void.

I further understand that this choice of Option D Beneficiary may be superseded if I leave a spouse to whom I

have been married for at least one year and with whom I am living with on the date of my death, or if living

apart for justifiable cause, and I have at least two years of creditable service.

__________________________________________________________________________________________

Name of Eligible Beneficiary

______________________________________________ _________________________________________

Beneficiary Date of Birth (Attach birth record) Beneficiary SSN

Beneficiary Address

______________________________________________ _________________________________________

Member Email: ________________________________________ Member Phone: _____________________

To be completed by witness to member signature above. The designated beneficiary may not witness.

Witness’ Signature: _____________________________________ Date: _____________________________

Witness’ Name (Print): ________________________________________