Metlife Change Of Beneficiary/spousal Consent Form (Page 2 of 2) in pdf

ERISA 403(b) Spousal Consent

Spousal Consent and Waiver

If your 403(b) plan is subject to ERISA please complete the appropriate section below.

For Non-Married Participants

q I certify that I am not married and spousal consent is not required.

Participant’s Signature ________________________________________________________________________________________________

For Married Participants

If you are married and designate a beneficiary(ies) other than your spouse for your death benefit, such designation will not be

effective unless your spouse indicates agreement with the designation by signing the Spousal Consent below.

Spousal Consent:

I hereby consent to the designation of the beneficiary(ies) listed above. I understand that (1) the effect of this designation

is to cause some or all of my spouse’s death benefit, or a portion of it, to be paid to someone other than me; (2) that each

beneficiary designation is not valid unless I consent to it; and (3) my consent is irrevocable unless my spouse revokes the

beneficiary designation. I acknowledge that if my spouse is currently under 35 years of age, this beneficiary designation

becomes ineffective on (a) the first day of the plan year in which he/she reaches age 35; or (b) the date of separation from

service, whichever comes first, and that I must complete a new spousal consent in order for such beneficiary designation to

become effective.

Spouse’s Signature _______________________________________

_____________________________________________________

Date

Notarization of Spouse’s Signature

STATE OF _________________________________________________

COUNTY OF ______________________________________________

The undersigned Notary Public certifies that __________________________________________ , personally known to me to be the

same person whose name is subscribed to the foregoing document, appeared before me in person, and acknowledged the

signature anddelivery of this instrument as his or her free and voluntary act, for the uses and purposes therein set forth.

Notary Public Signature: _________________________________________ Date: _______________________________________________

Print Name of Notary: ___________________________________________ My Commission Expires: ______________________________

Plan Representative Witness

The undersigned, with authority to act on behalf of the Plan, certifies that __________________________________________ , the

Participant’s spouse, appeared before me in person, and executed the foregoing document freely and voluntarily.

Plan Representative Signature: ___________________________________ Date: _______________________________________________

* If spousal consent is required but cannot be obtained, this form must be accompanied by an affidavit completed by the

participant and approved by the Plan Administrator. The affidavit must state that spousal consent is not needed or cannot

be obtained because: (1) the participant’s spouse cannot be found; or (2) the participant is legally separated from or has

been abandoned by the spouse (within the meaning of local law) and has a court order to such effect and no qualified

domestic relations order exists that requires spousal consent to this withdrawal.

Mailing Instructions

Mail this form to:

Overnight mail only:

Fax to:

MetLife

908-552-3403

P.O. Box 10356

4700 Westown Parkway, Ste. 200

Des Moines, IA 50306-0356

West Des Moines, IA 50266

403B BENECHANGE (07/08)

Metlife Change Of Beneficiary/spousal Consent Form Page 2

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