Designation of a Beneficiary Form
1. Plan Participant Information Employer Name: Plan Name: Participant Name: Home Address: City:
State:
Zip Code:
xxx-xx-
Social Security Number:
Birth Date:
Email Address:
Phone Number:
2. Revocation of Previous Designations I hearby revoke any Designation of Beneficiary I may previously have made under the above plan and designate the following as my
Beneficiary(ies) under the Plan. 3. Primary Beneficiary(ies)
Name
Per stirpes
Relationship
Social Security Number
Date of Birth
% Share
xxx-xx- xxx-xx- xxx-xx-
xxx-xx-
4. Contingent Beneficiary(ies) Name
Per stirpes
Relationship
Social Security Number
Date of Birth
% Share
xxx-xx- xxx-xx- xxx-xx-
xxx-xx-
5. Current Marital Status & Participant Approval A. ☐ I am not married. I understand that if I become married in the future, this form automatically ceases to apply, and I should file a new Designation of Beneficiary. B. ☐ I am married. If my spouse is not the only Primary Beneficiary, my spouse has signed the consent below. (If consent of your spouse cannot be obtained - e.g. cannot be located or is incapacitated – contact your employer for information about possible alternatives.) I understand that if my marital status changes, this Designation will nevertheless remain in effect until I file a new Designation. Participant Signature: Date: 6. Spouse’s Consent I hereby approve of, and consent to, the beneficiary designation adopted by my spouse as provided above. I understand that I am entitled to receive a spouse’s benefit under the Plan unless I consent to a different beneficiary designation. I also understand that the above designation has the effect of causing the death benefit under the Plan to be paid to another beneficiary. I further understand that my spouse may not change the primary beneficiary designation above without first obtaining my written consent. Spouse’s Name: Spouse’s Signature: Date:
7. Notary Public Witness or Plan Administrator Approval Sworn to, and witnessed by me, this Day of Name of Notary Public: Notary Public’s Signature: If not notarized, witnessed by Plan Trustee or Authorized Signer : Signature of Trustee/Authorized Signer :
(month),
.
Notary Public Stamp
Date:
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