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TMRS_0075 Supplemental Death Benefits Beneficiary DesignationFIVIII-M00MA Supplemental Death Benefit Beneficiary Designation I � If you are an active employee, this benefit is a one-time lump sum payment approximately equal to one year's salary based on the 12 months immediately preceding your month of death. P.O. Box 149153 Austin, Texas 78714-9153 This form allows you (as an active or retired employee) to designate a beneficiary to receive the Supplemental Death Benefits (SDB) due upon your death. Only employees and retirees of cities participating in the Supplemental Death Benefits (SDB) program should complete this form. M If you are a retired employee, this benefit is a one-time lump sum payment of $7,500. HOW LONG IS THE SDB BENEFICIARY DESIGNATION VALID? The designation on this form is valid until you submit another beneficiary designation to TIVIRS on a form prescribed by TIVIRS — at that time your SDB beneficiary designation on this form will become inoperative. You may designate up to three primary beneficiaries and up to three alternate beneficiaries. Unless directed otherwise in writing on this form, your benefits will be paid equally to the surviving primary beneficiaries, or equally to the surviving alternate beneficiaries if there are no surviving primary beneficiaries. Contact TIVIRS for instructions on how to provide for unequal distributions. 11 1 Pill � Ifyouvv|shtodes|gnateyourEstatuasbenefidary,p|casevvriteVnk/thevvord^ESTATE^inthespeoe provided for the name of the beneficiary. � U you wish tmdesignate a Charity as beneficiary, please write the name of the Charity (i.e., American Heart Association) in the space provided for the name of the beneficiary. IN |f you wish to designate aTrust, please write "Trustee of the (enter name of Trust hene)^ |n the space provided for the name of the beneficiary. Please ensure you have a legal trust agreement in place prior to designating a "Trust" un this form. TIVIRS will accept the designation of a Trust. However, we cannot assure that if and when a benefit becomes payable from this System, the designation will be legally valid. In other words, if the trustee does not accept or has died, or if the Trust has been revoked, or if for any other reason the designation is not legally sufficient at the time of the member's death, the benefit due from the System will be paid in accordance with the provisions of the TIVIRS Act as if no trust/trustee had been designated. Member's Name (first, middle, last) Social Security Number Mailing Address Daytime Phone Number City State Zip Employing City Name SDB BENEFICIARY DESIGNATION (LIMIT 3) Please read instructions before completing. Beneficiary's Full Name (first, middle, last) Social Security Number Sex: ❑ Male ❑Female Relationship (required) Date of B i rth (M M/D D/YYYY) Beneficiary's Full Name (first, middle, last) Social Security Number Sex: ❑ Male ❑Female Relationship (required) Date of B i rth (M M/D D/YYYY) Beneficiary's Full Name (first, middle, last) Social Security Number Sex: ❑ Male ❑Female Relationship (required) of Birth (MM /DD /YYYY) CUSTODIAN E THE TEXAS UNIFORM TRANSFERS T 1 S ACT You may designate a custodian if any beneficiary is under 21 years of age. See instructions provided with this form. Custodian's Name (first, middle, last) Custodian's Relationship to Beneficiary ALTERNATE S FICIA Y (LIMIT 3) Please read instructions before completing. Beneficiary's Full Narne (first, middle, last) Social Security Number Sex: ❑ Male ❑ Female Relationship (required) Date of Birth (MM /DD /YYYY) Beneficiary's Full Name (first, middle, last) Sex: ❑ Male ❑Female Relationship (required) Social Security Number Date of Birth (MM /DD /YYYY) Beneficiary's Full Narne (first, middle, last) Social Security Number Sex: ❑ Male ❑Female Relationship (required) Date of Birth(MM /DD /YYYY) MEMBER SIGNATURE E I E This beneficiary designation revokes all previous beneficiary designations I have made with regard to the Supplemental Death Benefits Fund which may be payable upon my death. Should 1, at some future time, decide to have my SDB payment paid to someone other than the person(s) listed above, I will make the change in writing on a form prescribed byTMRS. Should all primary and alternate beneficiaries named above predecease me and I fail to name another beneficiary, or in the event my relationship with all primary and alternate beneficiaries ceases, then this designation shall become inoperative as to those beneficiaries and any benefit payable from the Supplemental Death Benefits Fund shall be paid to the beneficiary entitled to receive my retirement benefit. I understand that if I name more than one primary or alternate beneficiary, the Supplemental Death Benefits will be paid to the surviving primary beneficiaries in equal shares (unless I have otherwise directed on this form) or in equal shares to the surviving alternate beneficiaries if I am not survived by any primary beneficiary(ies). By signing this form, I certify that I have read the instructions provided with this form. Member's Signature Date Signed (MM /DD /YYYY) Please read the instructions provided with this form. TMRS - P.O. Box 149153 • Austin, Texas 787149153 • 800.924.8677 • 512.476.7511 • FAX 512.476.5576 - www.TMRS.com � r M R s o o x 5 TMRS - 0075 - Revised 7 -2009 RULES 0 Only adults at least 21 years of age, financial institutions, corporations, or other legal entities may serve as custodians. 0 You cannot nominate two or more custodians to serve jointly. However, you may nominate a substitute custodian 10 serve in the event the first nominated custodian dies before any payment is made, declines, or is ineligible to serve. Please contact TIVIR5 for instructions on how to nominate a substitute custodian. � You may designate the same custodian for up to three minors. If one custodian is named for all three minors, that custodian would receive separate benefit payments for each minor. � When the minor beneficiary reaches age 21, the custodianship for that beneficiary is terminated and any TK4RSbenefits that become payable will be paid directly io that beneficiary. � The designated custodian can select any benefit option that the minor could select if the minor were an adult. � If there is an eligible custodian designated to receive benefits, there is no limit on the amount of benefits which can be paid to the custodian. � The minor's Social Security number is used for IRS reporting purposes.