Application - NYS Teachers' Retirement System
Application - NYS Teachers' Retirement System
Application - NYS Teachers' Retirement System
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Member Social Security Number<br />
– –<br />
Name and Address of Beneficiary(ies)<br />
PART 4 — DESIGNATION OF BENEFICIARY<br />
(NET-11.4)<br />
Please review all information on page 4 before completing this area.<br />
Any changes made on this application must be initialed.<br />
Check One: Primary Contingent<br />
First Name<br />
MI<br />
Last Name<br />
Street Address<br />
Street Address<br />
City<br />
State<br />
Zip Code<br />
–<br />
Date of Birth<br />
Male<br />
Benefi ciary Social Security Number<br />
Relationship<br />
/ /<br />
Month Day Year<br />
Female<br />
– –<br />
Spouse<br />
Child<br />
Other<br />
Name and Address of Beneficiary(ies)<br />
Check One: Primary Contingent<br />
First Name<br />
MI<br />
Last Name<br />
Street Address<br />
Street Address<br />
City<br />
State<br />
Zip Code<br />
–<br />
Date of Birth<br />
Male<br />
Benefi ciary Social Security Number<br />
Relationship<br />
/ /<br />
Month Day Year<br />
Female<br />
– –<br />
Spouse<br />
Child<br />
Other<br />
- 3 -<br />
Continued on Back
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