UNCLAIMED RETIREMENT BENEFIT AND PAYMENT FORM

UNCLAIMED RETIREMENT BENEFIT AND PAYMENT FORM

INSTRUCTIONS: Print this form, complete it in full, and mail to: Employees' Retirement System of Georgia Two Northside 75, Suite 300 Atlanta, GA 30318

You will receive a response from the Employees' Retirement System of Georgia within two months of receipt of completed form.

MEMBER OR PAYEE INFORMATION

Member Name:

Date of Birth:

SSN:

Last State Employer (if known):

Member ID: (if known)

Member Address:

City:

State:

ZIP:

Country:

CLAIMANT INFORMATION (IF OTHER THAN MEMBER OR PAYEE)

Claimant Name:

Relationship to Member:

Claimant Address:

City:

State:

ZIP:

Country:

Member Date of Death, if applicable (include death certificate)

IMPORTANT: Include copies of Guardianship / Power of Attorney / Letters of Administration, if applicable.

CONTACT INFORMATION

Phone Number:

e-mail:

DISCLAIMER: Completing this form does not guarantee that you will receive the funds. All payments are subject to statutory and plan limits. Payments are alo subject to audit. In the event of an overpayment, the receipient will be held personally liable for repayment.

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