Fillable Designation Of Beneficiary Form printable pdf download

DESIGNATION OF BENEFICIARY—EMPLOYEES

University of California Retirement Plan (UCRP) and Capital Accumulation Payment (CAP)

and UC-Sponsored Insurance Plans

UBEN 116 (R9/15) University of California Human Resources

example, enter “Mary Lou Smith” rather than “Mrs. John Smith.” If the

THIS FORM IS FOR USE BY EMPLOYEES ONLY.

beneficiary’s first name consists of initials only, enter “(IO)” (meaning

(Retirees, former employees and others use form UBEN 117 to

“Initials Only”) in parentheses following the person’s name. You should

name beneficiaries for the University of California Retirement

also provide your beneficiary’s address and Social Security number.

Plan and Capital Accumulation Payment—UCRP/CAP.)

If your beneficiary is a trust, you must enter the name of the trust.

• Use this form to name or change your beneficiary(ies) for

You should also provide the date of the trust and the trustee’s name,

lump sum death benefits from UCRP/CAP and/or certain

address, and the trust's taxpayer identification number.

UC-sponsored insurance plans. Plans are listed on the form.

If your beneficiary is a charity or other entity, you must enter the name

• You can name or change your beneficiary(ies) on the UCnet

and address. You should also provide the charity’s/entity’s taxpayer

website (ucnet.universityofcalifornia.edu). Select “AYS Online,”

identification number.

log on, and then choose “My Beneficiary.”

You may name as many beneficiaries as you like. If you name more

• If you do not name a beneficiary, payment will be made auto-

than one, the benefit will be paid in equal shares unless you specify the

matically in the order shown at the bottom right of this page.

share (%) each is to receive. If you specify shares, they must be whole

percentages (for example, 50% rather than 50.5%), and total shares

IMPORTANT NOTE: You CANNOT use this form to designate or

must add up to 100%. If any of your beneficiaries dies, that share will be

change beneficiaries for the Retirement Savings Program plans

divided proportionately among the remaining beneficiaries.

(Defined Contribution Plan, 403(b) Plan and/or 457(b) Plan). To

You may also designate secondary beneficiaries to receive benefits if

designate or change beneficiaries for those plans, call Fidelity

all primary beneficiaries are deceased.

Retirement Services at 1-866-682-7787 or visit the Fidelity website

You may name your estate as beneficiary.

CHANGING YOUR BENEFICIARY

GENERAL INFORMATION

You may change your beneficiary at any time either online (see shaded

Designation of a beneficiary may have significant tax and inheritance

box at left) or by submitting a new form. Once UC Human Resources ac-

consequences for your estate and for the beneficiary. Consult your

cepts the new designation, all previous designations become invalid. UC

attorney or tax advisor for more information.

Human Resources will confirm the changes either by sending an e-mail

If you are married, your spouse may have a legal interest in this

to your UC work address or by sending a notice to your home address.

designation of beneficiary. A beneficiary designation may be subject

In most cases, changes in your family situation—for example, marriage

to challenge if it will result in your spouse receiving less than his or her

—will not automatically alter or revoke your existing beneficiary

proportionate share of the benefit attributable to community property.

designations. A beneficiary designation generally remains valid

Beneficiary designations generally avoid probate unless the estate is named

until you submit a new one. However, if you are divorced and at the

as beneficiary. Consult your attorney for more information and advice.

time of your death your former spouse is still named as beneficiary on

the form you completed while you were married, the designation may

COMPLETING THIS FORM

be void. (Some exceptions apply. See California Probate Code 5600.)

You should review your beneficiary designations for the UCRP

If you have questions or need help, call your local Benefits Office.

whenever there is a change in your family situation.

General Instructions

You should also update your designations (either online or by

Either type this form or complete it in ink. This is a legal document, so

submitting a new form) if a beneficiary changes his or her address.

erasures or other corrections (including cross-outs) are not acceptable.

A will does not supersede a beneficiary designation.

Except for trust agreements, attachments are not acceptable.

Plan Designation

IF YOU DO NOT NAME A BENEFICIARY

Completing one form will designate your beneficiary(ies) for all plans in

If you do not name a beneficiary for any or all of the UC-sponsored

which you are enrolled except those enrolled in the Retirement Savings

plans in which you are enrolled, benefits will be paid to your survivors

Program plans. If you want to name different beneficiaries for different

as follows:

plans, you must complete a separate form for each plan. Be sure to write

the name of the plan(s) to which each form applies in the space provided.

• Legal spouse or domestic partner or, if none,

Personal Information

• Biological or adopted children** (step children are not considered

Provide all the information requested.

beneficiaries), or if none,

• Parents or, if none,

Primary/Secondary Beneficiary(ies)

If you need more than one page to name your beneficiaries, use

• Siblings (half siblings are not considered beneficiaries) or, if none,

multiple forms, marking them “Page 1 of 2,” “Page 2 of 2,” and so forth.

• Your estate.

Your beneficiary(ies) may be any person(s) you want to name.

* Nonresident alien or resident alien must obtain an Individual Taxpayer

“Person” includes any entity capable of taking and holding property.

Identification Number (ITIN). For information on applying for ITIN, visit

If your beneficiary is a person (including nonresident alien or resident

alien*), you must enter the person’s full name and date of birth. For

** Children of a deceased child share their parent’s benefits

Designation Of Beneficiary Form

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