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

I understand that, unless a valid beneficiary designation is in effect at the time my account becomes payable, my account under the plan

shall be payable to the first surviving class of the following:

• Widow or Widower,

• Surviving Children,

• Surviving Parents,

• Surviving Brothers or Sisters, then

• The Executors or Administrators of the estate of the participant upon whose death the payment becomes due.

I understand that if I do not make the following election, upon my death, assets in my plan account will be transferred to the investment

option designated by the employer in the adoption agreement as the default investment option for the plan.

c In the event of my death, I elect to have assets in my plan account remain invested in the investment options I elected and which are

in effect at the time of my death.

I hereby designate the following as my beneficiary(ies) under the plan. I understand that in the event of my marriage, divorce or remarriage, any

prior beneficiary designation is automatically revoked so long as written evidence is provided to the Program before any distribution request.

Participants naming a trust as either a primary or a contingent beneficiary are responsible for ensuring that sufficient documentation

of the underlying beneficiaries of the trust is delivered to the Plan Administrator in a timely manner as prescribed by law. Also, naming a

trust as a beneficiary has certain other legal requirements, as well as potential income and estate tax consequences. As the Program does

not provide advice regarding such matters, we recommend that you consult with your legal counsel.

If you name more than one primary or contingent beneficiary, the beneficiaries will share equally in any benefits unless a specific percentage

is provided.

NAME OF PRIMARY BENEFICIARY #1

DATE OF BIRTH

RELATIONSHIP

SOCIAL SECURITY NUMBER

NAME OF PRIMARY BENEFICIARY #2

DATE OF BIRTH

RELATIONSHIP

SOCIAL SECURITY NUMBER

If there are no primary beneficiaries living at the time of my death, I designate the following beneficiaries:

NAME OF CONTINGENT BENEFICIARY

DATE OF BIRTH

RELATIONSHIP

SOCIAL SECURITY NUMBER

NAME OF CONTINGENT BENEFICIARY

DATE OF BIRTH

RELATIONSHIP

SOCIAL SECURITY NUMBER

Use additional sheets as necessary.

5. SPOUSAL CONSENT (THIS SECTION IS REQUIRED IF YOU ARE NOT NAMING YOUR SPOUSE AS YOUR SOLE PRIMARY BENEFICIARY)

I understand that my spouse is a participant in the plan. I acknowledge that I have been told by the Plan Administrator that if my spouse

dies before receiving any distributions under the plan, I am entitled to receive my spouse’s account balance under the plan in one of the

following forms: (a) if my spouse’s plan is not a Profit Sharing Plan, in the form of monthly payments for the remainder of my lifetime or, if I

elect after my spouse’s death, in the form of a lump sum distribution or installments payments, or (b) if my spouse’s plan is a Profit Sharing

Plan, in the form of a lump sum distribution or installments payments. I understand that by consenting to the beneficiary designation above,

I am waiving my right to receive any benefits under the plan, and therefore, will not receive any benefits that would otherwise automatically be

paid to me upon my spouse’s death. I also understand that my consent is irrevocable unless my spouse revokes this beneficiary designation.

I hereby consent to the above beneficiary designation.

Choose one of the following:

c If this beneficiary designation is revoked, I permit future beneficiary designation changes by the participant without my consent.

I understand that, by making this election, my spouse will be able to designate a beneficiary other than the beneficiary or

beneficiaries named above without my consent.

c If this beneficiary designation is revoked, I DO NOT permit future beneficiary designation changes by the participant without

my consent.

SIGNATURE OF SPOUSE IF SOLE PRIMARY BENEFICIARY IS NOT THE SPOUSE

DATE

WITNESS TO SIGNATURE OF SPOUSAL CONSENT

DATE (MUST BE SAME AS SPOUSE)

(NOTARY PUBLIC OR AUTHORIZED PLAN REPRESENTATIVE OTHER THAN THE PARTICIPANT)

Page 2 of 2

Beneficiary Designation Form - Aba Retirement Funds Page 3

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