Beneficiary Form - Elevator Constructors Annuity And 401(K) Retirement Plan printable pdf download

Beneficiary Form

Elevator Constructors Annuity and 401(k) Retirement Plan

60041

GENERAL INFORMATION:

Please complete this form, including your signature and the date. Keep a copy for your records.

and forward the

original to the fund office at the address at the bottom of the page.

SOCIAL SECURITY NUMBER

FIRST NAME

LAST NAME

STREET ADDRESS

E-MAIL ADDRESS

CITY

STATE

ZIP

BIRTH DATE

MARITAL STATUS

MARRIED

SINGLE OR LEGALLY SEPARATED

BENEFICIARY DESIGNATION

(Check one box only)

Spouse Primary Beneficiary:

I would like my spouse to receive my entire account balance at my death.

Spouse's Name: _______________________________________________Spouse's Social Security # _______-______-_______ Spouse's Date of Birth:_____/_____/_____

day

Non-Spouse or Multiple Primary Beneficiaries:

I would like the following person(s) to receive my account balance upon my death:

(If division is other than equal shares, write in percentages.)

PRIMARY BENEFICIARY NAME

RELATIONSHIP

SOCIAL SECURITY NUMBER

PERCENT

PRIMARY BENEFICIARY NAME

RELATIONSHIP

SOCIAL SECURITY NUMBER

PERCENT

PRIMARY BENEFICIARY NAME

RELATIONSHIP

SOCIAL SECURITY NUMBER

PERCENT

If you are married and you have NOT elected your spouse as primary beneficiary, please have your spouse provide consent below.

SPOUSAL CONSENT:

I understand that I have a legal right to a death benefit equal to the participant's entire account balance. I consent to waive that legal right

in accordance with the beneficiary designation set forth above. I further understand and acknowledge that if I sign this form, no death benefit will be payable to me

except as provided above. I acknowledge that I have a right to limit my consent only to a specific beneficiary and that I voluntarily elect to relinquish such right.

SPOUSE’S SIGNATURE

DATE

NOTARY PUBLIC’S SIGNATURE

DATE

DATE COMMISSION EXPIRES

SECONDARY BENEFICIARY DESIGNATION

SECONDARY BENEFICIARY NAME

RELATIONSHIP

SOCIAL SECURITY NUMBER

PERCENT

SECONDARY BENEFICIARY NAME

RELATIONSHIP