Designation Of Beneficiary Form (Page 3 of 4) in pdf

Plan Name: NUSCO 401k Plan

Plan #: 35677

Designation of Beneficiary Form

A. Participant Information

Note:

The instructions for this form are an integral part of the form. You should use them to assist you. Also, if it is necessary to make corrections to any part

of this form, please do not use whiteout; you must place your initials next to the corrected or crossed-out words.

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Participant Name (First, MI, Last): ___________________________________________ Social Security #:

Participant Address: ______________________________________________________________________________________________________

City: _______________________________________________________ State: _____________

ZIP: _________________________________

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Phone (day):

Marital Status: (select one)

Single

Married

B. Primary Beneficiary(ies)

I understand that if I am married, my spouse shall automatically be my designated beneficiary unless I elect otherwise and my spouse consents to such election

as well as to the designation of the other beneficiary(ies). I hereby designate the following person or persons as primary beneficiary(ies) of my account under

the Plan(s) payable by reason of my death. If any primary beneficiary does not survive me, the share of that beneficiary shall be divided between the

remaining beneficiaries in proportion with their stated percentage of interest. If no primary beneficiary survives me, then my account shall go to my contingent

beneficiary(ies). (If additional space is needed for beneficiary information, attach a separate sheet of paper to the Designation of Beneficiary F orm with the

information noted below.)

1. Beneficiary’s Name: (First, MI, Last) _____________________________________________________________________ Share %:

Date of Birth: _____/_____/_____

Sex (M/F) _____

Social Security Number/Tax ID:

—

Relationship to Participant:

Spouse

Trust

Other: __________________________________

Address: ____________________________________________________________________________________________________________

City: __________________________________________________

State: _____________

ZIP: __________________________________

2. Beneficiary’s Name: (First, MI, Last) _____________________________________________________________________ Share %:

—

Date of Birth: _____/_____/_____

Sex (M/F) _____

Social Security Number/Tax ID:

Relationship to Participant:

Spouse

Trust

Other: __________________________________

Address: ____________________________________________________________________________________________________________

City: __________________________________________________

State: _____________

ZIP: __________________________________

C. Contingent Beneficiary(ies)

In the event that no primary beneficiary survives me, I hereby designate the following person or persons as contingent beneficiary(ies) of my account. If any

contingent beneficiary does not survive me, then the share of that beneficiary shall be divided between the remaining contingent beneficiaries in proportion with

their stated percentage of interest.

1. Contingent Beneficiary’s Name: (First, MI, Last) _____________________________________________________________ Share %:

—

Date of Birth: _____/_____/_____

Sex (M/F) _____

Social Security Number/Tax ID:

Relationship to Participant:

Spouse

Trust

Other: _____________

Address: ____________________________________________________________________________________________________________

City: __________________________________________________