Designation Of Beneficiary Form printable pdf download

Plan Name: NUSCO 401k Plan

Plan #: 35677

Beneficiary Designation Instructions

A beneficiary is a person, institution, charitable organization, or

Please note: Some retirement plans restrict whom you can elect

irrevocable or revocable Trust named by you, the participant,to

as a beneficiary for specific benefits and when you can change your

receive payment of benefits provided under the NUSCO 401k Plan in

election. If you designate one beneficiary for all plans in which you

the event of your death. You may designate more than one primary

are enrolled, you will be subject to these restrictions across all

beneficiary who will share the benefit. You may also designate one

plans.

or more contingent beneficiaries. A contingent beneficiary would

1. If these sections are not filled out completely, the form will be

receive payment only if the primary beneficiary or beneficiaries you

returned to you.

named died before you or disclaimed the right to receive payment

2. The beneficiary designation should not include wording such as

at the time that payment was to be made.

"either/or" or "and/or." You cannot designate unborn children as

All information must be typed or printed neatly, using upper-

beneficiaries. You can designate charitable organizations.

case letters and black ink. If it is necessary to make corrections

3. Use only whole-number percentages equaling 100%. For example,

to the beneficiary section, you must place your initials next to the

designations such as 33 1/3 or 33.3 are not acceptable.

corrected or crossed-out words. Do not use whiteout; otherwise the

form will be returned to you. If you have any questions about mak-

4. Naming an estate: Letters of appointment issued by the court nam-

ing a beneficiary designation, call Fidelity Investments toll-free at

ing the executor or administrator of the estate must be

1-800-261-401k and speak with a Participant Services

provided when a claim is filed. Please consult your attorney for

Representative. You can obtain additional Designation of

advice on the effect of this designation. No additional legal

Beneficiary Forms by logging on to Fidelity NetBenefits

documentation is required at this time.

or by calling Fidelity Investments at 1-800-261-

5. Naming a revocable or irrevocable trust: Provide the Trust's name

401k.

and address, name of one Trustee, the date of the Trust

Please make a copy of it for your files, and return the origi-

and the Trust's tax ID number. Do not send a copy of the trust

nal in the enclosed envelope or mail to:

agreement.

Fidelity Investments

If you would like to name more than two primary and two contin-

P.O. Box 5000

gent beneficiaries, you may attach a separate sheet of paper to the

Cincinnati, OH 45273-8212

Designation of Beneficiary Form with the applicable information.

A. Participant Information

D. Signature and Date

Complete all applicable information. You must check either single or

By signing and dating this section, you officially designate the per-

married. If you are married at the time of your death, federal law

son(s) listed on the form as your primary beneficiary(ies) and, if

generally requires that all benefits from the retirement plans be

applicable, your contingent beneficiary(ies) for this Plan. Your bene-

paid to your spouse, unless your spouse consents in writing to

ficiary designation(s) will not be valid unless this form is on file

another beneficiary designation and a Notary Public witnesses this

with the record keeper for this Plan.

consent.

E. Spousal Consent

B and C.

For the NUSCO 401k Plan, if you name someone other than, or in

Primary and Contingent Beneficiary(ies) Information

addition to, your spouse as your primary beneficiary(ies), your

Complete all applicable information for those whom you are naming

spouse must sign and date the form and have his/her signature wit-

as beneficiary(ies).

nessed by a Notary Public. A bank, law office or local government

office usually has a Notary Public on staff.

Please do not return this page.

Fidelity Investments Institutional Operations Company, Inc.

Designation Of Beneficiary Form

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