Tax-Deferred Retirement Account (Tdra) Enrollment Form For Selfemployed Ministers Page 2
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3Individual or Trust Name __________________________________________________________________________________
__________%
(first, middle, last/family name)
Mailing Address _________________________________________________________________________________________
(street, city, state, zip)
Primary Phone (
)
Relationship to Applicant/Trustee Name ________________________________
Social Security No./ITIN _______ - _____ - _________ Birth or Trust Date ________/________/________
Contingent Beneficiaries
Percentage
If all of your primary beneficiary(ies) die before you, any benefits payable in the event of your death will be paid to
of Benefit
your contingent beneficiary(ies). The total percentage to all contingent beneficiaries must equal 100%.
Individual or Trust Name __________________________________________________________________________________
__________%
(first, middle, last/family name)
Mailing Address _________________________________________________________________________________________
(street, city, state, zip)
Primary Phone (
)
Relationship to Applicant/Trustee Name ________________________________
Social Security No./ITIN _______ - _____ - _________ Birth or Trust Date ________/________/________
Individual or Trust Name __________________________________________________________________________________
__________%
(first, middle, last/family name)
Mailing Address _________________________________________________________________________________________
(street, city, state, zip)
Primary Phone (
)
Relationship to Applicant/Trustee Name ________________________________
Social Security No./ITIN _______ - _____ - _________ Birth or Trust Date ________/________/________
Individual or Trust Name __________________________________________________________________________________
__________%
(first, middle, last/family name)
Mailing Address _________________________________________________________________________________________
(street, city, state, zip)
Primary Phone (
)
Relationship to Applicant/Trustee Name ________________________________
Social Security No./ITIN _______ - _____ - _________ Birth or Trust Date ________/________/________
IV. SPOUSAL CONSENT
If you reside or have resided in a community or marital property state (which may include, but are not necessarily limited to, AZ, CA,
ID, LA, NV, NM, PR, TX, WA, and WI) and you are married, your spouse may need to complete this Section IV in order for you to
name any one other than, or in addition to, your spouse as a beneficiary. If you are not currently married and you become married in
the future, you must complete a new Beneficiary Designation Form. It is your responsibility to determine if this Section IV applies and
to determine if the spousal consent language below is sufficient to satisfy applicable state statutes. Your state may require this
Enrollment Form to be signed in the presence of a Notary Public.
SPOUSAL CONSENT. I am the spouse of the applicant. Due to the important tax consequences of giving up my interest in the funds
covered by this beneficiary designation, I have been advised to see a tax or legal professional. I hereby voluntarily and irrevocably give
the applicant any community property or marital interest I have in the funds covered by this beneficiary designation and consent to the
beneficiary designation(s) indicated above. I assume full responsibility for this consent.
Spouse Signature ____________________________________________________________ Date ________/________/________
Print Name _________________________________________________________________
Please have completed if your spouse's signature must be acknowledged by a Notary Public:
STATE OF ___________________________)
COUNTY OF _________________________)
On this __________ day of _______________, personally appeared before me the above named _________________________,
personally known to me, who, being duly sworn, deposes and says that he or she executed the foregoing consent.
Notary Public Signature ____________________________________ My commission expires _______/________/________
Page 2 of 3
TDRA Enrollment Form for Self-Employed Ministers 03-15
4927828v2
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