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2. 
3. DESIGNATION OF OPTION II BENEFICIARY BY MEMBERS WITH 10 OR MORE YEARS OF SERVICE CREDIT

5. Section 15.20 of the City of Roseville Employees’ Retirement System provides that any member who continues in the employ of the City after the date he/she acquires 10 or more years of service may nominate a beneficiary, whom the Board finds to be dependent upon the member for at least fifty percent of his/her support, to receive an Option II benefit in the event of the member’s death.

   I, hereby name the following individual as my Option II beneficiary in the event of my death as an active employee:

7. Beneficiary's Name
9. Date of Birth
10. Relationship
12. Address
14. City
15. State
16. Zip Code

18. I certify that I, and my beneficiary, have met the requirements of Section 15.20 and I understand that benefits will be paid in accordance with Section 15.20.  For more information, please refer to https://www.roseville-mi.gov/DocumentCenter/View/288/Employees-Plan-Document-PDF?bidId=  

    I understand that at any time prior to the effective date of my retirement, I may revoke this election and file another form with the Board selecting both an option and beneficiary of my choosing.

    I understand that this election is only effective if I continue in the employ of the City or upon becoming eligible for voluntary retirement. Upon separation of service prior to voluntary retirement, I may be a deferred vested member, however, I understand that no Option II benefits will be payable in the event of my death as a deferred vested member.

20. Electronic Signature Agreement - Member's 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.
22. Electronic Signature
24. 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.
26. Electronic Signature
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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

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