REQUEST FOR CHANGE OF BENEFICIARY
Active  
Retiree 
Employee No. __________________________
Social Security No. __________–________–______________
Telephone No. __________________________ 
In accordance with the provision of the law governing the Employees Retirement System of the Government of the Virgin Islands,
I, ____________________________________________________________________________________ , designate the following as
my beneficiary or beneficiaries in the event of my death: 
(1) 
______________________________________
________________________
___________________________
________________
(Print Name in full) 
(Beneficiary's date of birth) 
(Beneficiary's SSN) 
(Relationship) 
whose address is: ____________________________________________________________________________________________________________
(2) 
______________________________________
________________________
___________________________
________________
(Print Name in full) 
(Beneficiary's date of birth) 
(Beneficiary's SSN) 
(Relationship) 
whose address is: ____________________________________________________________________________________________________________
(3) 
______________________________________
________________________
___________________________
________________
(Print Name in full) 
(Beneficiary's date of birth) 
(Beneficiary's SSN) 
(Relationship) 
whose address is: ____________________________________________________________________________________________________________
(4) 
______________________________________
________________________
___________________________
________________
(Print Name in full) 
(Beneficiary's date of birth) 
(Beneficiary's SSN) 
(Relationship) 
whose address is: ____________________________________________________________________________________________________________
In the event the foregoing named person(s) do not survive me, my beneficiary shall be: 
(1) 
______________________________________
________________________
___________________________
________________
(Print Name in full) 
(Beneficiary's date of birth) 
(Beneficiary's SSN) 
(Relationship) 
whose address is: ____________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
If more than one beneficiary is named, the benefit is to be paid equally or on the survivor basis. Any prior designation
of beneficiary filed by me is hereby revoked. 
If the beneficiary or beneficiaries herein nominated shall not survive me and no other written nomination shall have
been filed by me with the System, then the beneficiary shall be in the order named: (a) my spouse; (b) my children and
descendants thereof by representation; or (c) my parents. 
The system is hereby requested and directed to make this designation a part of my Membership Record. 
Continued on the reverse side
GERS-BEN102  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
I reserve the right to change my beneficiary at any time by filing with the Board of Trustees of the Employees
Retirement System of the Government of the Virgin Islands, written notice of such change, duly acknowledged
before a Notary Public.
_________________________________________________________________
________________________________________________________________
Signature of Member 
Address 
________________________________________________________________
City, State, Zip
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-BEN102  REV 06