Designation Of Beneficiary And Waiver Of Pre-Retirement Survivor Annuity (Page 3 of 3) in pdf

Designation Of Beneficiary And Waiver Of Pre-Retirement Survivor Annuity Page 3

DESIGNATION OF BENEFICIARY and

WAIVER OF PRERETIREMENT SURVIVOR ANNUITY

Plan Name:

Participant’s Name:

Spouse's Consent

I hereby consent to the election made by my spouse to have the Plan's death benefit paid to a beneficiary other than me and/or

to have the death benefit paid to me in the form of a lump sum rather than as an annuity. The Plan's death benefit has been

explained to me, and I acknowledge that I understand (1) that the effect of such election is to cause my spouse's death benefit

to be paid to a beneficiary other than me; (2) that the beneficiary designation is not valid unless I consent to it; and (3) that my

consent is irrevocable unless my spouse revokes the beneficiary designation.

Date

Participant's Spouse

Witnessed by:

Plan Representative

State Of

)

County Of

)

On the

day of

, 20

, before me personally came

known to me to be the individual described, and who has acknowledged to me that he/she executed the foregoing document.

Notary Public of

My Commission Expires:

Signature of Notary Public

, 20

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Designation Of Beneficiary And Waiver Of Pre-Retirement Survivor Annuity Page 3