Designation Of Beneficiary Form Page 2
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1
2DESIGNATION OF BENEFICIARY FORM
1. Plan Name:
___________________________________________________________________
2. Participant Name:_________________________________________________________________________
3. Social Security No.:
4. Date of Birth: __________________________
5. Primary Beneficiary (attach additional sheets if necessary):
(a) Name:
Relationship:
Date of Birth:
% of benefits:
(b) Name:
Relationship:
Date of Birth:
% of benefits:
(c) Name:
Relationship:
Date of Birth:
% of benefits:
(d) Name:
Relationship:
Date of Birth:
% of benefits:
6. Contingent Beneficiary - in the event my Primary Beneficiary predeceases me (attach additional sheets if necessary):
(a) Name:
Relationship:
Date of Birth:
% of benefits:
(b) Name:
Relationship:
Date of Birth:
% of benefits:
(c) Name:
Relationship:
Date of Birth:
% of benefits:
(d) Name:
Relationship:
Date of Birth:
% of benefits:
7. Execution and Certification of Marital Status - please check the appropriate box and sign below.
”
Unmarried Participants. I certify that I am not married, I have no spouse, or my spouse cannot be
located. I designate as beneficiary the person(s) named above. However, if I hereafter marry, this will
revoke the designation and my spouse shall be my beneficiary. I will immediately inform the Plan
Administrator of any change in my marital status.
”
Married Participants. I certify that I am married to the person who has completed the spouse's consent
below. I designate as beneficiary the person(s) named above. I understand that any designation of a
beneficiary other than my spouse will not be effective unless the Spouse's Consent is completed below. I
will immediately inform the Plan Administrator of any change in my marital status.
_________________________________
Date
Participant
8. Spouse's Consent
I hereby consent to the election made by my spouse to have the Plan's death benefit paid to a beneficiary other than me. The
Plan's death benefit has been explained to me, and I acknowledge that I understand (1) that the effect of such election is to
cause my spouse's death benefit to be paid to a beneficiary other than me; (2) that the beneficiary designation is not valid
unless I consent to it; and (3) that my consent is irrevocable unless my spouse revokes the beneficiary designation.
______________________________________
Date
Participant
Witnessed by:
OR
Plan Representative
State Of
)
County Of
)
On the
day of
, 20
, before me personally came
,
known to me to be the individual described, and who has acknowledged to me that he/she executed the foregoing document.
Notary Public of
My Commission Expires:
Signature of Notary Public
, 20
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