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

(GC § 12479 – STD. 243)

Employee

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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)

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

First Contingent Designee

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Second Contingent Designee

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Third Contingent Designee

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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.


Employee

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