Commonwealth of Pennsylvania - Public School Employees' Retirement System 0187
5 N 5th Street Mail Center
Harrisburg PA 17101-1905
Toll-free: 1.888.773.7748 Nomination of Beneficiaries
www.psers.pa.gov
Fax: 717.772.3860 Addendum
PSRS- 1253 (07/2019)
This form is to be used in conjunction with a Nomination of Beneficiaries form (PSRS-187). List the first four Primary
and/or Secondary Beneficiaries on the Nomination of Beneficiaries form. Any additional Primary and/or Secondary
Beneficiaries should appear on this form. Do not duplicate the names of your beneficiaries listed on your Nomination of
Beneficiaries form on this Addendum.
A. PRIMARY BENEFICIARY(IES)
Percent Name (first, middle, last) Social Security Number Date of Birth Gender Address (street, city, state, zip)
B. SECONDARY BENEFICIARY(IES)
Order/
Percent
Name (first, middle, last) Social Security Number Date of Birth Gender Address (street, city, state, zip)
C. GUARDIAN
(1) Guardian's Name (first, middle, last) (2) Guardian's Address (street, city, state, zip) (3) Name(s) of Minor Beneficiary(ies)
D. CERTIFICATION
Member's Signature Member's Social Security Number Date of Signature
Month Day Year
Nomination of Beneficiaries Addendum Page 1 of 1
