Oklahoma County 457 (B) Plan - New Enrollment Participation Election Form (Page 2 of 2) in pdf

OKLAHOMA COUNTY 457(b) PLAN

DESIGNATION OF BENEFICIARY FORM

Social Security #: __________________________________________

Name: _______________________________________________________________________________________________________________

Mailing Address: ________________________________________ City: ________________________ State: _______ Zip Code: _____________

Date of Birth: ___________________________________________________

I hereby revoke any Designation of Beneficiary I may previously have made under the above Plan and designate the following as my Beneficiary under the

Plan:

Beneficiary Designation

Primary Beneficiary:

_________________________________ ____________________ ______________________ _________________________ __________________________

Name

Relationship

Social Security Number

Date of Birth

% Share

_________________________________ ____________________ ______________________ _________________________ __________________________

Name

Relationship

Social Security Number

Date of Birth

% Share

_________________________________ ____________________ ______________________ _________________________ __________________________

Name

Relationship

Social Security Number

Date of Birth

% Share

Contingent Beneficiary:

_________________________________ ____________________ ______________________ _________________________ __________________________

Name

Relationship

Social Security Number

Date of Birth

% Share

_________________________________ ____________________ ______________________ _________________________ __________________________

Name

Relationship

Social Security Number

Date of Birth

% Share

_________________________________ ____________________ ______________________ _________________________ __________________________

Name

Relationship

Social Security Number

Date of Birth

% Share

The Trustee will pay all sums payable under the Plan by reason of my death to the primary beneficiary, if he or she survives me. If no primary beneficiary

survives me, then to the contingent beneficiary, and if no named beneficiary survives me, then the Trustee will pay all amounts to my Estate. I understand

that this election form and/or beneficiary designation will remain in effect for the plan year and subsequent plan years until I provide the Employer with

other instructions. I understand I have a duty to review my pay records (pay stub, etc.) to confirm the Employer properly has implemented my salary reduc-

tion election. Furthermore, I have a duty to inform the Plan Administrator if I discover any discrepancy between my pay records and this Salary Reduc-

tion Agreement. I understand the Plan Administrator will treat my failure to report any withholding errors for any payroll to which my Salary Reduction

Agreement applies, by the cut-off date for the next following payroll, as my affirmative election to defer the amount actually withheld (including zero).

However, I thereafter may modify my deferral election prospectively, consistent with the Plan terms.

Signature of Participant:_________________________________________________________

Date________________________