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Group Term Life Insurance Change of Beneficiary

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					                                                                                                                     TCDRS-51
                                     Optional Group Term Life                                                          Revised
                                                                                                                       12/2007

                                      Beneficiary Designation                                                        Page 1 of 2



PURPOSE
To designate a beneficiary for the Optional Group Term Life benefit. This beneficiary designation does not affect your
retirement beneficiary. You can have different beneficiaries for this benefit and your retirement account.

INSTRUCTIONS
1. Complete the Member Information section.
2. Designate your primary and alternate beneficiary(ies) on this form.
3. Sign and date the bottom of the form.
4. If you want to name more than three primary or alternate beneficiaries, please include an
   Additional Beneficiary Attachment form (TCDRS-95).
5. Send the form to: TCDRS, Attn: Member Benefits, P.O. Box 2034, Austin,TX 78768-2034

REFERENCE
The Optional Group Term Life Program brochure.

ADDITIONAL INFORMATION
If you want the beneficiary for your retirement account to also receive your Optional Group Term Life benefit, please do
not fill out this form.
If you complete this form and later send in a new Beneficiary Designation form (TCDRS-06) for your retirement account,
TCDRS will not change your Optional Group Term Life beneficiary. Once you’ve designated a beneficiary using this form
you must send in a new Optional Group Term Life Beneficiary Designation form (TCDRS-51) to change your beneficiary.

CONTACTING TCDRS
If you have any questions, please call TCDRS Member Services at 800-823-7782.

TCDRS CANNOT ACCEPT
• An incomplete form            • Changes that are not initialed by the person signing the form
• A form that is not signed     • Any form filled out in pencil




TCDRS ★ P.O. Box 2034 ★ Austin,TX 78768-2034 ★ (512) 328-8889 or 800-823-7782 ★ Fax: (512) 328-8887 ★ www.tcdrs.org
                                                       Optional Group Term Life                                                                                                TCDRS-51
                                                                                                                                                                                 Revised
                                                                                                                                                                                 12/2007

                                                        Beneficiary Designation                                                                                                Page 2 of 2


                                                                     MEMBER INFORMATION
 First Name                                 Middle Initial or Name                          Last Name                           Birth Date               Social Security Number


 Address                                                                                                             Daytime Phone Number


 City                                                                  State                   Zip Code              How else can we contact you?




                                                                     PRIMARY BENEFICIARY
Benefits will be divided equally among all persons listed as primary beneficiaries, unless otherwise noted by you on this form.
 Beneficiary Name                                                                              Birth Date              Relationship to You                   Social Security Number


 Address                                                                                                    City                   State                     Zip Code


 Beneficiary Name                                                                              Birth Date              Relationship to You                   Social Security Number


 Address                                                                                                    City                   State                     Zip Code


 Beneficiary Name                                                                              Birth Date              Relationship to You                   Social Security Number


 Address                                                                                                    City                   State                     Zip Code



                                                  Custodian under the Texas Uniform Transfers to Minors Act
                                             To be named for those primary beneficiaries listed above who are under 18 years of age at my death.
 Custodian’s Name (must be at least 21 years of age)                                Relationship to You                               Daytime phone number


 Address                                                                                                    City                   State                     Zip Code




                                                    ALTERNATE BENEFICIARY (OPTIONAL)
 Benefits will be divided equally among all persons listed as alternate beneficiary, unless otherwise noted by you on this form.
 Beneficiary Name                                                                              Birth Date              Relationship to You                   Social Security Number


 Address                                                                                                    City                   State                     Zip Code


 Beneficiary Name                                                                              Birth Date              Relationship to You                   Social Security Number


 Address                                                                                                    City                   State                     Zip Code


 Beneficiary Name                                                                              Birth Date              Relationship to You                   Social Security Number


 Address                                                                                                    City                   State                     Zip Code



                                                  Custodian under the Texas Uniform Transfers to Minors Act
                                             To be named for those primary beneficiaries listed above who are under 18 years of age at my death.
 Custodian’s Name (must be at least 21 years of age)                                Relationship to You                               Daytime phone number

 Address                                                                                                    City                   State                     Zip Code



                                                                     MEMBER CERTIFICATION
 I hereby designate the beneficiary(ies) named on this form to receive any benefit payable from the Optional Group Term Life Insurance program.
 All previous beneficiary designations for the Optional Group Term Life Insurance Program are revoked by filing this form with TCDRS. Should a bene-
 ficiary designated on this form predecease me, or if I become divorced from the designated beneficiary, then this designation is revoked with respect
 to that beneficiary and benefits would be paid to the surviving primary beneficiaries, or to the surviving alternate beneficiaries if I am not survived by
 any primary beneficiary. Payments will be made in equal shares unless I have provided other instructions in writing on this form.
 Member Signature                                                                                                                  Date

 X
                                                   Any corrections or whiteouts must be initialed.
TCDRS ★ P.O. Box 2034 ★ Austin,TX 78768-2034 ★ (512) 328-8889 or 800-823-7782 ★ Fax: (512) 328-8887 ★ www.tcdrs.org

				
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Description: This form and instructions help you designate a beneficiary for the Optional Group Term Life benefit, which is distinct from your retirement beneficiary. You must fill out the Member Information, designate your beneficiary, and sign and date the form. If you have more that three beneficiaries, you will need to include an attachment form listing them. If the beneficiary who will receive this benefit will also receive your retirement account, you should not fill this form out or send it in. To have your form processed, you need to complete the form in pen, sign and date it, and initial any changes made.