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Get WI ET-2320 2021-2024

ET-2320 REV 3/6/2015 Personally identifiable information such as your Social Security number birth date etc. will not be used for any purpose other than for the administration of the benefit programs administered by ETF. Who Completes a Beneficiary Designation If you are the owner of a Wisconsin Retirement System account from which a death benefit or life insurance benefit would be payable upon your death you may file a Beneficiary Designation. Most WRS participants some alternate payees former spouses/domestic partners of participants and some beneficiaries of deceased participants are eligible to file. Wisconsin Department of Employee Trust Funds P. O. Box 7931 Complete if applicable Beneficiary Designation Madison WI 53707-7931 etf*wi. gov 1-877-533-5020 toll free Wis. Stat. 40. 02 8 a and 40. 74 Do not submit to your employer Type or print in ink Your name First Beneficiary of Alternate Payee of Refer to instructions on reverse Middle I. Last Your Social Security number Former/maiden - Your birth date MM/DD/CCYY Your address Street number and street name / City State Your weekday telephone number Include area code ZIP Code Any benefits payable by the Wisconsin Retirement System and Life Insurance program at my death shall be paid in EQUAL SHARES unless otherwise specified to the following primary beneficiary ies who survive me. Relationship PRIMARY Name First Middle I. Last SSN Birth date MM/DD/CCYY Address street city state ZIP code In the event all primary beneficiaries die before me the death benefit shall be paid in equal shares unless otherwise specified to the following secondary beneficiaries who survive me. SECONDARY TERTIARY following tertiary beneficiaries who survive me. If you want this designation to apply only to specific benefit plan s or account s use this space to specify the benefit plan s or account s to which you want this designation to apply. See Effective for all benefit plans and accounts section on the reverse side before completing this section* I understand that Wis. Stat. 943. 395 provide criminal penalties for making false or fraudulent claims on this form and hereby certify to the best of my knowledge and belief the above information is true and correct. Signature Do not print Date signed MM/DD/CCYY DATE SIGN Note The date the form is signed is not the date it becomes effective. A Beneficiary Designation form does not become effective until received and approved by the Department of Employee Trust Funds. The person filing the designation must still be alive when ETF receives the form* An acknowledgment will be sent when this designation has been reviewed and accepted* Invalid designations will be rejected and returned to you. If no Beneficiary Designation is on file WRS death benefits and life insurance benefits will be paid according to the statutory standard sequence in effect on the date of death as explained in the Naming Standard Sequence section* Special Note to Annuitants If you selected a WRS joint and survivor annuity when you retired you can never change the named survivor that you named on your WRS annuity application* Filing a Completing a Beneficiary Designation Clarity.

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