Beneficiary Designation Form Instructions Page 3
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3BENEFICIARY DESIGNATION FORM - PAGE 2 OF 2
employer Plan number
social security number
name (Please Print)
___ ___ ___ ___ ___ ___
___ ___ ___ - ___ ___ - ___ ___ ___ ___
___________________________________________________________________
3. sPoUsaL consent
sPoUsaL consent aPPLies to (1) Most 401 PLans if eLected by the eMPLoyer and
(2) aLL 457 and 401 PLans if yoU LiVe in a coMMUnity ProPerty state.
457 Plan: If you are married and live in a community property state (AZ, CA, ID, LA, NV, NM, TX, WA, or WI), you must generally name your spouse as a primary beneficiary for at least 50% of
the account unless your spouse consents to waive this right. your spouse’s written consent must be witnessed by a notary public.
401 Plan: If you are married, most 401 plans require your spouse to be the primary beneficiary for 100% of the account unless your spouse consents to waive this right. your spouse’s
written consent must be witnessed by your employer’s plan representative or a notary public. Please read the instructions if you live in a community property state (AZ, CA, ID, LA,
NV, NM, TX, WA, or WI) and your 401 plan does not require spousal consent to name a non-spouse beneficiary.
spousal consent (to be completed by the participant’s spouse):
By signing below, I agree to waive my beneficiary designation in my spouse’s account as outlined above. I understand the effect of this designation is to cause some or all of my spouse’s death
benefit to be paid to someone other than me and each beneficiary designation is not valid unless I consent to it.
_________________________________________________________
____ ___/____ ____ /____ ____ ____ ____
signature of Participant’s spouse
Month
Day
Year
_________________________________________________________
Print name of Participant’s spouse
SPOUSAL CONSENT IS REQUIRED TO BE WITNESSED BY*:
or
Employer’s Plan Representative
Notary Public
Signature of Spouse witnessed this ______ day
Subscribed and sworn before me this ______ day of ______________________ (month), 20____
of ________________________ (month), 20______
_________________________________________________
Notary Public’s Signature
__________________________________________________
My commission
Employer Representative’s Signature
Notary Public SEAL ___________________________
expires _____________
__
__________________________________________________
Print Name of Employer Representative
*457 PLAN PARTICIPANTS WHO LIVE IN A COMMUNITY PROPERTY STATE MUST HAVE THE SPOUSAL CONSENT WITNESSED BY A NOTARY PUBLIC.
4. aUthorization
____ ___/____ ____ /____ ____ ____ ____
________________________________________________________________
Participant signature
Month
Day
Year
_________________________________________________________
____ ___/____ ____ /____ ____ ____ ____
employer signature (if required)
Month
Day
Year
please keep a copy of your completed form for your records.
ICMA-RC • Attn: Workflow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400 • En Español 800-669-8216 • • Fax 202-682-6439
FRM570-005-0213-6291-385
REVISED 8/2013
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