Fillable Beneficiary Designation Form - Aba Retirement Funds (Page 2 of 3) in pdf

FORM 16 05/15

BENEFICIARY DESIGNATION FORM

ABA Retirement Funds Program (the “Program”)

Customer Contact Center: 800.348.2272

P.O. Box 5142 • Boston, MA 02206-5142

Website:

Complete this form to designate a beneficiary for your account in a full service plan. This form will replace all existing beneficiary information

for this plan. Please note the following:

• The Employer's dated signature is required in Section 3.

• If you are changing your beneficiary(ies) due to a marital status change, you must also submit a Participant Data Change Form and

evidence such as a marriage certificate or divorce decree.

• If you are married and not naming your spouse as the sole primary beneficiary, you must obtain his or her consent as witnessed

by a notary or an Authorized Plan Representative.

1. EMPLOYER INFORMATION

Program Plan Number: ___ ___ ___ ___ ___ ___ Employer Tax ID Number: ___ ___ – ___ ___ ___ ___ ___ ___ ___ IRS Plan Number: ___ ___ ___

Employer’s Name: ______________________________________________ Employer’s Business Phone Number: (

)

–

2. PARTICIPANT INFORMATION

Participant’s Name: ______________________________________________ Social Security Number: ___ ___ ___–___ ___–___ ___ ___ ___

Sex: c M

c F

Marital Status: c Single c Married

Date of Birth: ___ ___ /___ ___ /___ ___ ___ ___

3. SIGNATURES (THE EMPLOYER'S DATED SIGNATURE IS REQUIRED)

SIGNATURE OF PARTICIPANT (REQUIRED)

DATE (REQUIRED)

SIGNATURE OF AUTHORIZED PLAN REPRESENTATIVE ON BEHALF OF THE EMPLOYER REQUIRED)

DATE (REQUIRED)

4. BENEFICIARY INFORMATION

Complete this section in its entirety.

I hereby certify that I am a/an (Check one):

c Unmarried Participant—I understand that since I am not married, I may designate anyone as my beneficiary on the following page.

I understand also that this beneficiary designation will be invalid upon my marriage and will be automatically revoked.

c Married Participant

c Under Age 35 c Over Age 35

I understand that because I am married, my spouse is required to be my sole primary beneficiary under the plan unless my spouse

consents to the designation of another beneficiary by validly consenting and signing the spousal waiver section on the following page.

I understand that by designating a beneficiary other than my spouse, I am waiving the benefits my surviving spouse would otherwise

receive upon my death if my spouse survives me and that the spousal consent and waiver below applies only to my current spouse.

Moreover, I acknowledge that if I remarry, this beneficiary designation will not be effective unless it is refiled and my new spouse

consents to a new beneficiary by completing another Beneficiary Designation Form. I understand that I can reinstate

my spouse as my sole primary beneficiary at any time without my spouse’s consent.

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