FOR RETIREMENT USE ONLY FORM 4 (REV. 3/21)
APPLICANT'S SOCIAL SECURITY NUMBER
APPLICANT’S NAME
First Initial Last
HOME ADDRESS
Number and Street
City State ZIP Code
PRIMARY BENEFICIARY(IES) All money shall be paid in equal shares Check if you used an additional Form 4
to the primary beneficiary(ies) who are living at the time of my death. to name additional primary beneficiaries.
BENEFICIARY’S NAME RELATIONSHIP _______________
First Initial Last
BENEFICIARY’S ADDRESS _____________________________________________________________________________________________
BENEFICIARY’S NAME RELATIONSHIP _______________
First Initial Last
BENEFICIARY’S ADDRESS _____________________________________________________________________________________________
CONTINGENT BENEFICIARY(IES) If all primary beneficiaries die before me all money shall Check if you used an additional Form 4 to
be paid in equal shares to the following person(s) who are living at the time of my death. name additional contingent beneficiaries.
BENEFICIARY’S NAME RELATIONSHIP _______________
First Initial Last
BENEFICIARY’S ADDRESS _____________________________________________________________________________________________
BENEFICIARY’S NAME RELATIONSHIP _______________
First Initial Last
BENEFICIARY’S ADDRESS _____________________________________________________________________________________________
TO THE MARYLAND STATE RETIREMENT AGENCY: I authorize the Maryland State Retirement Agency to pay any benefits due upon my death to my designated beneficiary(ies). I
agree on behalf of my estate, heirs, and assigns that payment by the agency releases the agency from any further obligation regarding these benefits. I direct the agency to pay any benefits
to my estate if I have not designated any beneficiary(ies) or if they all die before me. I understand that I may change my beneficiary(ies) at any time by filing a new Designation of Beneficiary
form with the Maryland State Retirement Agency. Any new Designation of Beneficiary form I file will replace this form. I understand that payment due to a minor shall be made only to a
legally appointed adult. SIGN IN THE PRESENCE OF A NOTARIAL OFFICER (Notary Public, Clerk of the Court, etc.)
Signature Date Signed ___________________
MARYLAND STATE RETIREMENT AGENCY
120 EAST BALTIMORE STREET
BALTIMORE, MARYLAND 21202-6700
DESIGNATION OF BENEFICIARY
IMPORTANT: Please return completed form to the address listed above. Print clearly and read
the instructions first. Fill in all sections. Retain a copy for your records.
Gender: Birthdate:
(M or F) Month Day Year
CHECK ONE: Active Vested Retired (If retiring, retirement date ______________ )
IMPORTANT: If you are retired under Option 2, 3, 5 or 6, STOP. You cannot use this form. You
must complete a Form 66 to initiate any beneficiary changes.
Gender: Birthdate:
(M or F) Month Day Year
Gender: Birthdate:
(M or F) Month Day Year
Gender: Birthdate:
(M or F) Month Day Year
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FORM 4 (REV. 3/21)
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PLEASE READ THESE INSTRUCTIONS CAREFULLY BEFORE FILLING OUT THIS FORM
1. Important terms/definitions:
a. Active Member: a member who is currently
employed by a participating employer, including a
member who is currently on a Qualifying Leave of
Absence
b. Vested Member or Former Member: a member or
former member who is no longer employed by a
participating employer, but who is eligible to receive a
deferred vested allowance based on the number of
years of service credit earned during employment
c. Retiree: an individual who has separated from
employment with a participating employer and
receives a monthly retirement allowance
d. Primary Beneficiary: person(s) to receive any
benefits payable on your death
e. Contingent Beneficiary: person(s) to receive any
benefits payable upon your death only if all of the
primary beneficiaries die before your death
2. Purpose of this form:
This Form applies to the Employees’ and Teachers’
Retirement and Pension Systems, Correctional Officers’
Retirement System, Law Enforcement Officers’ Pension
System and State Police Retirement System.
If you are an Active Member or a Vested Member
or Former Member, use this form to name or change the
person or persons you want to receive any payable death
benefits. The beneficiary(ies) of an active member may
be entitled to a one-time payment equal to your annual
salary at death plus any member contributions with
accumulated interest. The beneficiary(ies) of a vested
member or former member may be entitled to payment of
any member contributions with accumulated interest.
Important note for active members who are
married: If you die as an active member and you meet
certain requirements related to your age and/or the years
of service, your spouse may be eligible to elect to receive
a monthly survivor allowance instead of the standard
death benefit payable for members who die during
employment. If you want your spouse to be eligible to
make this election, you must name your spouse as your
sole/only primary beneficiary.
If you are a Retiree, use this form to change your
beneficiary(ies) only if you chose the Basic Allowance,
Option One or Option Four at retirement. If you chose
Option Two, Three, Five or Six at retirement, STOP. You
may not use this form to change your beneficiary.
Changing your beneficiary under Options Two, Three,
Five or Six is a two-step process. You must first submit a
Request for Calculation of Joint Survivorship by a Retiree
Considering Changing a Beneficiary (Form 66) in order to
receive an estimate of your recalculated allowance based
on the new proposed beneficiary. This form is available
on the Retirement Agency website at sra.maryland.gov or
by calling a retirement benefits specialist. When you
receive a written estimate of the recalculated allowance,
you will be provided with a different form (Form 67) to
complete and submit if you decide to change your
beneficiary.
Important note for participants of more than one State
system: If you participate in more than one system, you must
properly complete and submit a Designation of Beneficiary
(Form 4) for each system. Members of the Judges’
Retirement System please use Form 4.1. Members of the
Legislative Retirement System please use Form 55.
3. Number of beneficiaries:
Fill out only the spaces needed. If you need space for
more beneficiaries, complete another form and check the
box or boxes to show that you have used a second form.
4. Full names of beneficiaries:
Give the full names of your beneficiaries. For example,
“Mary Jones” not “Mrs. John Jones.”
5. Who can be a beneficiary:
Beneficiaries do not need to be related to you.
Minors: You may name a minor (child less than 18
years of age) as a beneficiary, but in some cases
payments can only be made to the legal guardian of a
minor. You cannot use this form to name a legal guardian
for minor children.
Your estate: You may name “my estate” as your sole
primary beneficiary. Do not name a personal
representative of your estate as your beneficiary. Instead,
use the space for the beneficiary’s address to show the
address of the person or business that will administer
your estate. If your estate is named as the primary
beneficiary, do not designate contingent beneficiaries.
Trustee: If you have established an Agreement of
Trust or Testamentary Trust, you may name “Trustee as
appointed by Agreement of Trust or Will” in the space
provided for the beneficiary’s address. Give the address
of the Trustee or of the person or business that will
administer the trust.
Church or charitable organization: List the
complete corporate or legal name.
6. How benefits are divided among your beneficiaries:
Any benefits due at your death are paid in equal shares to
the living primary beneficiaries named on your
Designation of Beneficiary form. If you name multiple
primary beneficiaries, and one of the primary
beneficiaries dies before you, the total benefits due at
your death are divided in equal shares among the
remaining primary beneficiaries. If all of the primary
beneficiaries are deceased on your death, any benefits
are payable in equal shares to your contingent
beneficiaries who are then living. A deceased
beneficiary’s share of your total benefits cannot be paid to
that deceased beneficiary’s heirs. Payment is made only
to the living beneficiaries listed on your Designation of
Beneficiary form
7. Notarization
This form is not valid unless notarized by a Notary Public.
Properly completed forms should be mailed to: Maryland
State Retirement Agency, 120 E. Baltimore St., Baltimore,
MD 21202-6700
Important note for all individuals filing this form: This
form must be filed with the Maryland State Retirement
Agency and is not considered to be filed if it is not submitted
to the MSRA, but instead submitted to the employing agency.
MSRA shall use the last form properly completed and filed
with MSRA on or before the date of death to determine who is
entitled to receive any benefits owed.
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FORM 4 (REV. 3/21)
