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RETIREMENT- Beneficiary Change Form

  1. Roseville Logo
  2. Change of Nomination of Beneficiary
  3. I, hereby revoke and cancel my previous nomination of beneficiary and direct the Board of Trustees of the City of Roseville Employees' Retirement System, in the event of my death before becoming eligible for pension benefits provided by the Retirement System, to pay the amount of accumulated contributions standing to my credit in the Annuity Savings Fund to:

  4. If Living

    If living, otherwise pay to:

  5. Electronic Signature Agreement - Employee Signature

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  6. Electronic Signature Agreement - Witness Signature

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

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  8. This field is not part of the form submission.