Form Center

2. 
3. Change of Nomination of Beneficiary : City of Roseville Employees' Retirement System / City of Roseville Police & Fire Retirement System

5. 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:

7. Name of Primary Beneficiary
9. Relationship
10. Email Address
12. Address
14. City
15. State
16. Zip Code
18. Phone Number
20. If Living

    If living, otherwise pay to:

22. Name of Contingent Beneficiary
24. Relationship
25. Date of Birth
27. Address
29. City
30. State
31. Zip Code
33. Phone Number
37. 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.

    1. I agree.
39. Electronic Signature
41. 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.

    1. I agree.
43. Electronic Signature
Leave This Blank:


45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit

* indicates a required field