Fillable Beneficiary Designation Form (Page 2 of 3) in pdf

Section F - Participant Certification and Authorization (you must sign this section)

I, the participant, hereby instruct the Plan to distribute my death benefit to the designated beneficiary(ies) herein. I acknowledge that:

• If I am married, I must obtain spousal consent if all or a portion of my death benefit is to be paid to someone other than my spouse.

• If the Plan’s normal form of benefit is an annuity, I have read the Qualified Pre-Retirement Survivor Annuity Notice and provided a properly

executed waiver. If not, this designation is not valid.

• I reserve the right to revoke or change any beneficiary designation (with spousal approval, if applicable) by submitting a new form.

• This form is not valid if it is not received by the Plan in good order before my death and/or if there is no Primary or Contingent beneficiary(ies)

living upon my death.

• This form supersedes any prior beneficiary designation and, if my beneficiary designation is valid under the Plan, identifies all current Primary and

Contingent beneficiary(ies).

• I understand that if I do not provide a valid beneficiary designation, and the Plan does not provide for a default beneficiary, then my beneficiary

will be my estate.

_____________________________________________________________

__________________________

Participant’s Signature

Date

Section G - Spousal Consent (complete only if the participant is married)

I certify that I am the spouse of the participant and I hereby voluntarily consent to the participant’s (i.e., my spouse) beneficiary designation herein. I

acknowledge that:

• If the Plan’s normal form of benefit is an annuity, I have received and read the Qualified Pre-Retirement Survivor Annuity Notice.

• I understand the effect of such beneficiary designation is to cause my spouse’s (i.e. the Participant) death benefit, or portion of it, to be paid to a

beneficiary other than me.

• Each beneficiary designation is not valid unless I consent to it.

• My consent is irrevocable unless my spouse revokes the beneficiary designation.

____________________________________________________________

_________________________

Participant Spouse’s Signature

Date

Section H - Witness Certification and Signature

(Plan Administrator or Notary completes)

I certify that the married participant’s spouse personally appeared before me and acknowledged that she/he signed the Section G - Spousal Consent as

her/his free act and deed.

If the plan administrator does not witness the spouse’s signature, a Notary must witness it.