Designation of Person(s) Authorized to Receive Warrants

First name Required

Middle name

Last name Required

Name of Employing State Agency Required

Agency Location Required (city)

Pursuant to Section 12479 of the Government Code, I hereby designate the following person(s), trust, estate, or corporation which, notwithstanding any other provision of the law, shall be entitled upon my death to receive all state warrants that would have been payable to me had I survived.

NOTE: Direct deposit payments are not subject to the provisions of this designation.

Important: This is NOT a designation for payment of death benefits or refund of employee retirement contributions. A form PERS-BSD-241, Beneficiary Designation, must be completed to file a designation with the California Public Employees' Retirement System for death benefits.

Primary Designee (Must be 18 years of age or older)

First name Required

Middle name

Last name Required

Relationship Required

Phone Required

Address Required

Apt / Suite / Other (optional)

Unit #

City

State

ZIP Code

Contingent Designee(s) (Must be 18 years of age or older)

First Contingent Designee

First name

Middle name

Last name

Relationship

Phone

Address

Apt / Suite / Other (optional)

Unit #

City

State

ZIP Code

Second Contingent Designee

First name

Middle name

Last name

Relationship

Phone

Address

Apt / Suite / Other (optional)

Unit #

City

State

ZIP Code

Third Contingent Designee

First name

Middle name

Last name

Relationship

Phone

Address

Apt / Suite / Other (optional)

Unit #

City

State

ZIP Code

I hereby revoke all designations that I have previously filed.

The primary designated person shall be the designated person that receives the warrants. If the primary designated person predeceases the employee, the next designated person who survives the employee will receive the warrant(s).

If the above-named designee does not file a written request with the personnel/payroll office of my employing state agency/campus for such warrants within sixty (60) days after the date of my death, this designation shall be and become null and void.

This designation will remain in full force and effect during my employment with any California state agency/campus until revoked in writing by me.

Designation of Person(s) Authorized to Receive Warrants
Human Resources

(GC § 12479 – STD. 243)

Employee

Primary Designee (Must be 18 years of age or older)

Contingent Designee(s) (Must be 18 years of age or older)

First Contingent Designee

Second Contingent Designee

Third Contingent Designee

Employee

Designation of Person(s) Authorized to Receive WarrantsHuman Resources

(GC § 12479 – STD. 243)

Employee

Primary Designee (Must be 18 years of age or older)

Contingent Designee(s) (Must be 18 years of age or older)

First Contingent Designee

Second Contingent Designee

Third Contingent Designee

Employee

Designation of Person(s) Authorized to Receive Warrants
Human Resources