Subject: Member forms
Author: TRS Communications
Keywords: TRS; Teachers' Retirement System; Illinois Teachers; Nomination of beneficiary; forms; address; phone number; email; e-mail; Designation; Automatic designation; beneficiaries; dependents; spouse; children; nob; mib; mibd

Member Information and Beneficiary Designation Form

First Name

Middle Initial

Last Name

Maiden Name

Member Social Security number
(Required for tax-reporting purposes.)

Date of birth | Gender | Male | Female | Home telephone number
Street Address | Work telephone number | Extension
City | Cell phone number
State | | | Zip | Email address

Please select one:
I have included my proof of birth that is required to receive any future benefits from TRS. Acceptable proof of birth includes a copy of the birth certificate, valid passport, valid driver’s license or other state-issued identification card.
My birth certificate is already on file with TRS.

Member of another Illinois public employee retirement system (specify system’s name)
By completing this form, a TRS member or annuitant designates beneficiaries to receive death benefits. Information provided on this form will become part of the member’s permanent TRS record and will determine distribution of death and survivor benefits. This designation revokes any prior designation. If this current designation is found to be invalid, the most recent designation on file with TRS will remain in effect. Eligibility is determined by the survivor’s status at the time of the member’s death. Monthly survivor benefits can be paid only to eligible dependent beneficiaries.*
If the automatic designation is selected, do not complete the Beneficiary Refund or Survivor Benefits sections.
| Automatic Designation (commonly selected by members with a spouse or civil union partner and/or minor children)

In lieu of designating specific beneficiaries, I elect that my dependent beneficiaries, as determined at my death, receive a
beneficiary refund and/or survivor benefits. If no dependent beneficiary survives, benefits will be paid to my estate.

If automatic designation is not selected, you must complete the Beneficiary Refund section. Alternate beneficiaries will receive benefits should primary beneficiaries predecease the member. When a beneficiary designation includes more than one person, the benefits are divided equally among the living beneficiaries of that class (primary or alternate).
Beneficiary Refund | | Survivor Benefits

First name

Primary Beneficiaries
Last	Date of birth

Relationship

First name

Primary Beneficiaries
Last	Date of birth

Relationship

First name

Alternate Beneficiaries
Last	Date of birth

Relationship

First name

Alternate Beneficiaries
Last	Date of birth

Relationship

If additional space is required, attach a separate sheet designating primary and alternate persons for Beneficiary Refund and Survivor Benefits. Also include the last four digits of your Social Security number, signature, and date.

Certification: By signing, I certify that this information is correct. I am aware that pursuant to the Illinois Pension Code, 40 ILCS 5/1-135, any person who knowingly makes any false statement or falsifies or permits to be falsified any record in an attempt to defraud the Teachers’ Retirement System is guilty of a Class 3 felony. Please be advised that, if the TRS Board has reasonable suspicion that a false
record has been filed with the System, it is required to report the matter to the state’s attorney for investigation.

Member’s signature (mandatory) | Date
Signature pursuant to a General Power of Attorney is not accepted by TRS.	*See page 2 for more information.
You may fax the form to TRS at (217) 787-2269

https://www.trsil.org/MIBD_form	page 1	14006015   Online form	8/17

Types of Beneficiaries

The member may designate a beneficiary to receive survivor benefits. If this individual is a dependent beneficiary, then he or she is eligible to receive either monthly benefits or a lump-sum payment. However, if the member designates a nondependent beneficiary, only a lump-sum benefit is payable. Monthly benefits cannot be paid to dependent beneficiaries if a nondependent beneficiary is also designated and survives the member.

Dependent beneficiary. A spouse to whom the member has been married for at least one year, except where a child is born of the marriage in which case the qualifying period is not applicable; a civil union partner to whom the member has been partnered for at least one year; an unmarried natural or adopted child under 18, or between ages 18 and 22 if he or she is a full-time student in an accredited educational institution, or an unmarried child of any age who is dependent by reason of a physical or mental disability and claimed as a dependent on the member’s final federal income tax return; a dependent parent who received from the member at least half of his or her support for the 12-month period immediately prior to the member’s death.

Nondependent beneficiary. Any other designated person or entity who is not a dependent beneficiary.

Types of Benefits

Beneficiary Refund. This benefit is only payable upon death. The member cannot elect to receive this benefit. This refund includes a return of the member’s retirement contributions, statutorily required interest on the retirement contributions, and member contributions paid toward the annual increases in annuity. This refund is payable: to a designated beneficiary; if no beneficiary is designated, to the surviving spouse or civil union partner; or if no one is designated and there is no surviving spouse or civil union partner, to the member's estate. After retirement, this amount is reduced by the amount of retirement benefit payments made to the member.

Survivor Benefits. A beneficiary is eligible to receive a lump-sum survivor benefit if the member’s death occurs during TRS-covered employment or in the 12-month period immediately following the last day of earnings, while on a creditable leave of absence, or while receiving disability benefits.

A dependent beneficiary may also be eligible to receive monthly survivor benefits if certain requirements are met by the member before death.

Children, unless named as a beneficiary on the MIBD form, are only eligible for benefits if they are the children of the surviving parent who will receive monthly benefits. In the case of a divorce, if the member names the new spouse or civil union partner and had children with the prior spouse or civil union partner, those children are not eligible for monthly survivor benefits.

For instructions on designating a trust, please contact TRS.
A Qualified Illinois Domestic Relations Order (QILDRO) on file with TRS when the member dies may affect distribution of survivor benefits. For more information about QILDROs, please consult the QILDRO publication available on the TRS website.
As with all TRS benefits, death and survivor benefits must be paid in accordance with the Pension Code,
40 ILCS 5/16. If there is any discrepancy between the information on this form and applicable law, the law controls.

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