Fillable Nycers F501 Form in PDF

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The NYCERS F501 form is a designation of beneficiary form used to nominate individuals to receive a post-retirement lump-sum death benefit. This form allows retirees to specify primary and contingent beneficiaries, ensuring that their benefits are distributed according to their wishes after their passing. If no beneficiaries are designated, the benefit will go to the retiree's estate.

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Fillable Nycers F501 Form in PDF

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Article Guide

The NYCERS F501 form is a critical document for individuals who wish to designate beneficiaries for their post-retirement lump-sum death benefit. This form allows members to specify one or more primary beneficiaries who will receive the benefit upon their death after retirement. In the event that a primary beneficiary predeceases the member, the form also provides space to name contingent beneficiaries who will receive the benefit instead. If neither primary nor contingent beneficiaries are alive at the time of the member's death, the lump-sum payment will default to the member's estate. The form requires essential personal information, including the member's name, Social Security number, and contact details, as well as the same for each nominated beneficiary. Additionally, if any of the beneficiaries are minors, the member must complete guardian information on a separate form. To ensure the validity of the beneficiary designations, the form must be signed and notarized. It is crucial for members to understand the implications of their choices, as this designation can significantly affect the distribution of their benefits after their passing. For any questions regarding the completion or implications of the F501 form, members are encouraged to reach out to the NYCERS Call Center for assistance.

NYCERS USE ONLY

F501

Mail completed form to: *501* 30-30 47th Avenue, 10th Fl

Long Island City, NY 11101

Designation of Beneficiary(ies)

Post-Retirement Lump-Sum Death Benefit

This application is for those who wish to nominate a beneficiary(ies) to receive a post-retirement lump-sum death benefit. If the designated Primary Beneficiary(ies) predeceases you, the lump-sum payment will be paid to your designated Contingent Beneficiary(ies). If none exists, the lump-sum benefit will be paid to your estate. NOTE: If the address you provide on this form is different from your address in our system, the new address will become your official address in our records. If you have any questions, contact our Call Center at 347-643-3000.

Member Number OR

Pension Number

Last 4 Digits of SSN

Phone Number

First Name

( )

M.I. Last Name

in Care of (if applicable)


Address		Apt. Number

City	State		Zip Code

I understand that at the time of my death after retirement, the lump-sum death benefit will be paid to my surviving designated Primary Beneficiary(ies). If the designated Primary Beneficiary(ies) predeceases me, the lump-sum death benefit will be paid to my designated Contingent Beneficiary(ies). If none exists, the lump-sum death benefit will be paid to my estate.

I, the undersigned, nominate as my beneficiary(ies) for the lump-sum death benefit payable on my death after retirement:

First NameM.I. Last Name

Beneficiary	Full Social Security Number	Date of Birth
Beneficiary			[MM/DD/YYYY]
			[MM/DD/YYYY]
		/			/
	Address
Primary	City
	City
	If this beneficiary is a minor, check here and complete the
	If this beneficiary is a minor, check here and complete the
	guardian information on Form 137
	First Name			M.I.		Last Name
Beneficiary
Beneficiary	Full Social Security Number	Date of Birth [MM/DD/YYYY]
	Full Social Security Number	Date of Birth [MM/DD/YYYY]
		/			/
	Address
Primary	City
	City

If this beneficiary is a minor, check here and complete the guardian information on Form 137

Relationship

Apt. Number

Relationship

Apt. Number

R12/16

Page 1 of 2

NYCERS USE ONLY

F501

Mail completed form to:

30-30 47th Avenue, 10th Fl

Long Island City, NY 11101

Member Number OR	Pension Number	Last 4 Digits of SSN

If the foregoing Primary beneficiary(ies) should predecease me, I hereby nominate the following as Contingent beneficiary(ies) for the above Post-Retirement Lump-Sum Death Benefit.

Contingent Beneficiary

First Name			M.I.		Last Name
Full Social Security Number	Date of Birth
Full Social Security Number	Date of Birth	[MM/DD/YYYY]
Address	/			/
Address
City

If this beneficiary is a minor, check here and complete the guardian information on Form 137

Relationship

Apt. Number

I am nominating my Estate as my beneficiary for my post-retirement lump-sum death benefit. I understand that in order for this selection to be valid I may not write in any other beneficiary's name on this form, and I have, in fact, left all other designation of beneficiary sections on this form blank.

Should I survive all designated beneficiaries, the post-retirement lump-sum death benefit shall be paid to my Estate or to such other beneficiary or beneficiaries as I shall hereafter nominate by filing another designation of beneficiary form with NYCERS.

Signature of Member	Date

(Witnesses necessary only if mark is	Witnessed by (1):

used for signature)	Witnessed by (2):

This form must be acknowledged before a Notary Public or Commissioner of Deeds

State of		County of		On this	day of		2 0		, personally appeared
before me the above named,						, to me known, and known to

me to be the individual described in and who executed the foregoing instrument, and he or she acknowledged to me that he or she

executed the same, and that the statements contained therein are true.					If you have an official seal, affix it
Signature of Notary Public or
Signature of Notary Public or
Commissioner of Deeds

Official Title

Expiration Date of Commission

Sign this form and have it notarized, THIS PAGE

R12/16

Page 2 of 2

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Fact Name	Details
Purpose of Form	The NYCERS F501 form is used to designate beneficiaries for a post-retirement lump-sum death benefit.
Beneficiary Hierarchy	If the primary beneficiary predeceases the member, the benefit goes to the contingent beneficiary. If none exist, it goes to the estate.
Minor Beneficiaries	Special provisions apply for minor beneficiaries. The form requires additional guardian information if a minor is designated.
Notarization Requirement	The form must be notarized or acknowledged by a Commissioner of Deeds to be valid.
Governing Law	This form is governed by New York State laws regarding pension and retirement benefits.

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