Beneficiary/address/status Change Form
Download a blank fillable Beneficiary/address/status Change Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Beneficiary/address/status Change Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1BENEFICIARY / ADDRESS / STATUS CHANGE FORM
Plan Name or Employer Name
BLUE MOUNTAIN HEALTH SYSTEM PENSION PLAN (403B)
Check Applicable Box:
Name Change
Beneficiary Change
Address Change
Other _______________________
Participant Name
Participant SS#
Date of Birth
Address
Home/Cell Phone
Date of Hire
City, State Zip
Email
______I am married
If married, you must elect your spouse as the sole 100% primary beneficiary unless he/she completes and signs the
Spousal Consent section below.
_____ I am not married
I hereby certify that I am not now married and I understand that if I should become married in the future my spouse
would automatically become my Primary Beneficiary, unless he or she consents to another beneficiary.
PRIMARY BENEFICIARY(IES):
(must equal 100%)
Add Social Security
Name:
Share%
Relationship:
Address
Number if Available
CONTINGENT BENEFICIARY(IES):
(must equal 100%)
Add Social Security
Name:
Share%
Relationship:
Address
Number if Available
SPOUSAL CONSENT
(This Section MUST be completed if you are married and your spouse is not designated as your 100% Primary Beneficiary)
I am the legal spouse of the participant named above. I understand that the law requires my consent before my spouse can name someone
other than myself to be the primary beneficiary of his/her benefits under the plan named. I consent to the beneficiary designation adopted by my
spouse above. I understand that this eliminates all or a portion of the benefits otherwise payable to me from the plan if my spouse dies. I further
understand that my spouse may not change the beneficiary designation without first obtaining my written consent.
____________________________________________________ Date: ________________________
Spousal Signature:
____________________________________________________ Date: ________________________
Notary Public:
This consent is valid only if the spouse’s signature is acknowledged before a notary public
If I am married and did not name my spouse as 100% Primary Beneficiary, I have completed the Spousal Consent Section. I understand that if I
outlive my Primary Beneficiary, benefits will be paid to my estate on my death unless I designate a Secondary Beneficiary(ies). This change in
beneficiary revokes any prior beneficiary election(s) on record.
Participant Signature: ____________________________________________________ Date: ________________________
Submit Completed Form to Your Employer / Plan Administrator
07/2010
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business