Member Resources

Beneficiary Designation Form for Death Benefits

Beneficiary Designation Form Instructions

If you would like to list more than the allotted number of beneficiaries for either the Primary or Secondary Beneficiary sections please click here to print the Beneficiary Designation Form for Death Benefits. You can print as many copies of the form as you need for the desired number of beneficiaries. At the same link you can also find detailed instructions on the second page for filling out the Beneficiary Designation Form for Death Benefits.

Individuals appointed as a Power of Attorney for a member must contact the Austin Police Retirement System directly. Please be prepared to provide a copy the Power of Attorney form to the Austin Police Retirement System. Do not complete the Beneficiary Designation Form for Death Benefits online or attempt to mail one.

Note: Secondary Beneficiary(ies) listed are only entitled to collect the death benefits if the Primary Beneficiary(ies) are deceased.

Please mail or hand deliver the original Beneficiary Designation Form for Death Benefits to Austin Police Retirement System if you chose not to complete the electronic version. Our mailing address and location can be found here.

Questions or Concerns please contact our office at (512) 416-7672.

	indicates a required field
SECTION A: MEMBER INFORMATION
Social Security Number
First Name
Middle Initial
Last Name
Address

City
State
Zip Code
Marital Status	Single Married
Work Status	Active Retired
SECTION B: PRIMARY BENEFICIARY(IES) I wish to designate the person(s) named below to be my beneficiary(ies) for a tax free death benefit of $10,000 (or a proportionate amount if the member retired under the Proportionate Program). I understand that if I do not designate a beneficiary, my beneficiary may be determined according to APRS governing statute, Article 6243n-1 and/or according to the laws of the state in which I live, which I understand may be a more costly process for my heirs. I understand that I may designate my estate as beneficiary and must provide a court document showing the executor's or administrator's authority.
First Name
Middle Initial
Last Name
Address

City
State
Zip Code
Relationship
DOB
Social Security Number
Contact Number	ext. include area code
Percentage	% Equal Distribution

First Name
Middle Initial
Last Name
Address

City
State
Zip Code
Relationship
DOB
Social Security Number
Contact Number	ext. include area code
Percentage	% Equal Distribution

First Name
Middle Initial
Last Name
Address

City
State
Zip Code
Relationship
DOB
Social Security Number
Contact Number	ext. include area code
Percentage	% Equal Distribution
SECTION C: SECONDARY BENEFICIARY(IES) By clicking here, I am indicating I do not want to name a second beneficiary for death benefits. By clicking here, I am indicating that I want to list my estate as a second beneficiary for death benefits. It is my responsibility to provide legal documents to the System showing the executor's or administrator's authority before payment can be made. If primary beneficiary(ies) does not survive me, pay benefits to the named beneficiary(ies) as follows:
First Name
Middle Initial
Last Name
Address

City
State
Zip Code
Relationship
DOB
Social Security Number
Contact Number	ext. include area code
Percentage	% Equal Distribution

First Name
Middle Initial
Last Name
Address

City
State
Zip Code
Relationship
DOB
Social Security Number
Contact Number	ext. include area code
Percentage	% Equal Distribution

Estate of
SECTION D: SIGNATURE AND DATE I understand that the Texas Penal Code, Section 37.10, states that it is an offense to (1) make a false entry, or false alteration of a governmental record, (2) present a document with knowledge of its falsity, or (3) impair the verity or legality of the record. Offenses may result in legal actions.
Full Legal Name
Date

site by white lion

Member Resources

Beneficiary Designation Form for Death Benefits

SECTION A: MEMBER INFORMATION

SECTION B: PRIMARY BENEFICIARY(IES)

SECTION C: SECONDARY BENEFICIARY(IES)

SECTION D: SIGNATURE AND DATE