Beneficiary Form
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1
2BENEFICIARY FORM
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Name___________________________________________________________________________________
SS# __________ – _______ – _______________ Employer Code ___________________________ Suffix _______
Primary Beneficiary
SS# __________ – _______ – _______________
1. Name_____________________________________________
Relationship________________________________________
Date of Birth______________ Percentage____________
SS# __________ – _______ – _______________
2. Name_____________________________________________
Relationship________________________________________
Date of Birth______________ Percentage____________
SS# __________ – _______ – _______________
3. Name_____________________________________________
Relationship________________________________________
Date of Birth______________ Percentage____________
SS# __________ – _______ – _______________
4. Name_____________________________________________
Relationship________________________________________
Date of Birth______________ Percentage____________
PERCENTAGES MUST EQUAL 100% AND NOT EXCEED 100% IN EACH CATEGORY
Contingent Beneficiary
SS# __________ – _______ – _______________
1. Name_____________________________________________
Relationship________________________________________
Date of Birth______________ Percentage____________
SS# __________ – _______ – _______________
2. Name_____________________________________________
Relationship________________________________________
Date of Birth______________ Percentage____________
SS# __________ – _______ – _______________
3. Name_____________________________________________
Relationship________________________________________
Date of Birth______________ Percentage____________
SS# __________ – _______ – _______________
4. Name_____________________________________________
Relationship________________________________________
Date of Birth______________ Percentage____________
PERCENTAGES MUST EQUAL 100% AND NOT EXCEED 100% IN EACH CATEGORY
Do not check this box if you have chosen a primary/contingent beneficiary above.
My estate will be my primary beneficiary until I submit another properly completed Beneficiary Form. I understand that
distributions from my estate may be required to be approved by probate court according to applicable state law.
I hereby designate the above beneficiary(ies) to receive benefits payable under the Plan, if any, in the event of my death.
____________________________________________________________
______________________________________
Participant's Signature
Date
OHIO-0781-0515/WEB
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Parent category: Legal