ELECTION OF OPTIONAL BENEFITS 
(Please print all information on document.) 
Date: ____________________________________
Employee No.: _____________________________
Social Security No.: _________________________
Election by Married Member: 
I, _________________________________________________________________, do hereby elect a lesser service
retirement annuity, with the provision that my beneficiary receive an annuity as provided in the law governing
Optional Benefits of the Employees Retirement System; payment to my beneficiary to begin upon my death. 
Election by Unmarried Member:
I, ________________________________________________________________, do hereby elect a lesser service
retirement annuity for the designated beneficiary named below. 
Designation of Beneficiary: 
The name of my beneficiary under the election made herein is ______________________________________ who 
is related to me as _____________________________, (SSN) __________________________________, and whose
date and place of birth is: (Date)  _______–________–___________   (Place of Birth) ______________________ .
mm          dd               yyyy
I hereby certify that the information stated above is correct and if any error has been made, I agree that the
amount payable by the Employees Retirement System may be adjusted to the amounts which would have been
payable had no error been made herein. I also understand that I cannot change this option once my retirement
becomes final. My retirement becomes final when any retirement benefit payment is cashed or deposited. 
I hereby elect the "Full Option Benefit" at a semi-monthly cost of $ ____________________________________ .
I hereby elect the "Half Option Benefit" at a semi-monthly cost of $ ____________________________________ . 
In event of separation, death, etc., Optional Benefits cannot be revoked. ___________________ 
(Please initial) 
Mailing Address of Beneficiary: 
_________________________________________________
(Signature of Member) 
____________________________________
_________________________________________________
(Signature of Spouse) 
____________________________________
_________________________________________________
(Signature of Analyst) 
Territory of the U.S. Virgin Islands 
}
District of
} ss: 
On this ___________day of________________________ , before me personally appeared __________________________________,
known to be the individual whose named is subscribed in the foregoing instrument and acknowledge that ______________________
executed the same as __________________________ free and voluntary act. 
______________________________________________________
Notary Public
Commission Expires  _____________________________________
GERS-BEN106 REV 06
GOVERNMENT EMPLOYEES RETIREMENT SYSTEM
3438 Kronprindsens Gade, GERS Complex - STE 1, St. Thomas, VI 00802-5750 • (340) 776-7703 • Fax (340) 776-4499
3005 Orange Grove, Lot #5, Christiansted, St. Croix, VI 00820-4313 • (340) 773-5480 • Fax (340) 773-5497