Section 6 - IMRF

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.