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Primary Beneficiaries Name of Beneficiary First Name Middle Initial Last Name Relationship to Member Address City State ZIP PERSBSD509P 8/08 Page 1 of 2 Put name and Social Security number at the top of every page. Please contact CalPERS for more specific information. If you are completing a Post Retirement Lump Sum Beneficiary Designation form for a CalPERS member attach a copy of the document that grants you the authority to act on the member s.

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