Section 6 - IMRF
Section 6 - IMRF Section 6 - IMRF
Exhibit 6O Page 2 of 4 If you are naming a trust Please provide the number and/or date of the trust. Secondary Beneficiary(ies) Your Secondary Beneficiary(ies) will receive the death benefit payable by IMRF if no Primary Beneficiary survives. You can name any person, church, trust, charity or organization as your Secondary Beneficiary. You may also name more than one Secondary Beneficiary. Signature, date and returning the completed form You must sign, date, and file this form with IMRF for it to be effective. You can mail the completed form to IMRF directly, or you can give the completed form to your employer, who will mail it to IMRF. The information on this form does not become effective until it is on file in IMRF’s Oak Brook or Springfield office, even if your employer has a copy. IMRF Form 6.11 (Rev 06/12) page 2 of 2
DESIGNATION OF BENEFICIARY IMRF Form 6.11 (Rev. 06/12) Please print or type — use black ink and do not use a highlighter on the form. Exhibit 6O Page 3 of 4 1. Member Information Employee Name Social Security Number John J. Doe ______ 0 0 0 - _____ 0 0 - ________ 0 0 0 0 Mailing Address (street address; city; state; zip+4 if known) Birthdate (MM/DD/YYYY) 123 Oak Street 04/01/1981 Anywhere, IL 60000 Daytime Telephone No. ( 0 0 0 ) 0 0 0 - 0 0 0 0 Marital Status Never Married X Married Civil Union Divorced Widowed Gender of Spouse Spouse’s Last Name First Name Middle Initial Maiden (if applicable) Marriage/Civil Union Date (MM/DD/YYYY) Doe Janet M. 06/14/2004 Male Female 2. Primary Beneficiary(ies) (For your spouse to be eligible for a Surviving Spouse pension, he/she must be your ONLY primary beneficiary.) Refer to instructions if naming a minor or a trust. First Name Last Name Social Security Number Relationship % Share (optional) to each Janet Doe 0 0 0 - 0 0 - 0 0 0 0 Wife 100 IMRF Form 6.11 (Rev. 06/12) Important: If the total of all primary beneficiary shares does not equal 100%, or if you leave the percentages blank, IMRF will NOT process the form. 3. Secondary Beneficiary(ies) (Will receive IMRF death benefits if no Primary Beneficiary survives.) 4. Signature (write, do not type or print) of member only (Form will not be accepted if someone other than member signs form.) X Read the conditions on the reverse side. Date Completed form may be mailed to: Illinois Municipal Retirement Fund 2211 York Road, Suite 500, Oak Brook, IL 60523-2337 1-800-ASK-IMRF (1-800-275-4673) Fax 1-630-706-4289 TOTAL 100% First Name Last Name Social Security Number Relationship % Share (optional) to each NOTE: After the employer enrolls a member online, IMRF mails a partially pre-populated Designation of Beneficiary form to the member’s home with a cover letter and self-addressed, postage-paid envelope. Important: If the total of all secondary beneficiary shares does not equal 100%, or if you leave the percentages blank, IMRF will NOT process the form. TOTAL 100% The letter confirms the member’s participation in IMRF and asks the member to complete and return the Designation of Beneficiary form.
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Exhibit 6O<br />
Page 2 of 4<br />
If you are naming a trust<br />
Please provide the number and/or date of the trust.<br />
Secondary Beneficiary(ies)<br />
Your Secondary Beneficiary(ies) will receive the death benefit payable by <strong>IMRF</strong> if no Primary<br />
Beneficiary survives. You can name any person, church, trust, charity or organization as your<br />
Secondary Beneficiary. You may also name more than one Secondary Beneficiary.<br />
Signature, date and returning the completed form<br />
You must sign, date, and file this form with <strong>IMRF</strong> for it to be effective.<br />
You can mail the completed form to <strong>IMRF</strong> directly, or you can give the completed form to your<br />
employer, who will mail it to <strong>IMRF</strong>. The information on this form does not become effective until it is<br />
on file in <strong>IMRF</strong>’s Oak Brook or Springfield office, even if your employer has a copy.<br />
<strong>IMRF</strong> Form 6.11 (Rev 06/12) page 2 of 2