Form Gp34795-10 - Beneficiary Designation/change Page 3
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4Minor Beneficiary - UTMA: ONLY COMPLETE IF THE BENEFICIARY LISTED ABOVE IS A MINOR.
If any proceeds become payable to a beneficiary who is then a “minor” as defined in the applicable Uniform Transfers
to Minors Act, as specified herein, such proceeds shall be paid to
(Name)
(Address)
as custodian for such beneficiary:
(Check One Only) See instructions on Page 4.
under the Iowa Uniform Transfers to Minor Act.
under the Uniform Transfers to Minor Act of the state where the beneficiary shall reside at the time of payment. In the event
the beneficiary resides in California or Ohio at the time of payment, the custodianship is to continue until the beneficiary
reaches the age of
for California (insert 18, 19, 20, 21, 22, 23, 24 or 25) or
for Ohio (insert 18, 19, 20 or 21).
In the event a substitute custodian is needed, the following is/are nominated, in the order named:
Name
Address
Name
Address
If no state is specified (by name or description) above, or if the state so specified has not enacted the Uniform Transfers to
Minors Act, or if the law of the state so specified does not provide for such payment to a custodian, the custodianship shall be
established under the Iowa Uniform Transfers to Minors Act. If the specified Uniform Transfers to Minors Act would require the
beneficiary's custodianship to terminate at or before the time of payment, the proceeds payable to that beneficiary shall be paid
to the beneficiary rather than to a custodian.
Section III
Signature
Read important instructions on Page 4 before signing.
Signature of employee
Date signed
Note: make a copy of Page 1, 2, and 3 for your records and distribute copy to employee.
Print
Page 3 of 4
GP34795-10
05/2014
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