Eligibility of Retired Employee for Survivor's Benefits (RS 6355)

1. Read the requirements for this form on page 2 of the form.

2. In Part A, enter your:

• Name
  
• Social Security number
  
• Date of birth

3. In Part C, choose option A or B

• If you choose option A, enter beneficiaries
  

4. Do NOT sign this form unless in front of a notary public

5. Send or bring this form to Human Resources: