Beneficiary designation
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- Name Social Security No. _ _ _-_ _ -_ _ _ _
- 3. Spouse’s Consent
- Spouse’s Signature Date _ _ / _ _ / _ _ _ _
- 4. Certification of marital status
- Plan Participant Signature Date _ _ / _ _ / _ _ _ _
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> BENEFICIARY DESIGNATIONPlease complete, sign and submit this form to your Human Resources Representative or Plan Administrator for processing. For clarity purposes, please print all data. Plan IDParticipant Name (First) (Middle Initial) (Last) Mailing Address City/State/ZIP Code Social Security No. _ _ _ - _ _ - _ _ _ _ Date of Birth _ _ / _ _ / _ _ _ _ Marital Status Married Single As a Participant in the above Plan, I hereby designate the following individual(s) as my primary and alternate (contingent) Beneficiaries in the event of my death prior to the date on which my benefits commence to be paid under the Plan. If I have designated a non-Spouse Beneficiary, my Spouse has consented to the designation below before a notary public. If I am not married, I have completed the “Certification of Marital Status” below. 1. Primary BeneficiaryName Social Security No. _ _ _-_ _ -_ _ _ _Mailing Address Date of Birth _ _ / _ _ / _ _ _ _City/State/Zip Code Relationship Percentage % Name Social Security No. _ _ _-_ _ -_ _ _ _Mailing Address Date of Birth _ _ / _ _ / _ _ _ _City/State/Zip Code Relationship Percentage % Name Social Security No. _ _ _-_ _ -_ _ _ _Mailing Address Date of Birth _ _ / _ _ / _ _ _ _City/State/Zip Code Relationship Percentage % 2. Alternate Beneficiary (IES)If my Primary Beneficiary is deceased at the time of my death, I designate the following as my Alternate Beneficiary(ies) under the terms of the above Plan. Name Social Security No. _ _ _-_ _ -_ _ _ _Mailing Address Date of Birth _ _ / _ _ / _ _ _ _City/State/Zip Code Relationship Percentage % Name Social Security No. _ _ _-_ _ -_ _ _ _Mailing Address Date of Birth _ _ / _ _ / _ _ _ _City/State/Zip Code Relationship Percentage % Name Social Security No. _ _ _-_ _ -_ _ _ _Mailing Address Date of Birth _ _ / _ _ / _ _ _ _City/State/Zip Code Relationship Percentage % Name Social Security No. _ _ _-_ _ -_ _ _ _Mailing Address Date of Birth _ _ / _ _ / _ _ _ _City/State/Zip Code Relationship Percentage % 3. Spouse’s ConsentI hereby consent to the Beneficiary(ies) designated 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 Beneficiary(ies) designated above. 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 on this form without first obtaining my written consent. Spouse’s Signature Date _ _ / _ _ / _ _ _ _The signature of the participant’s spouse by law must be witnessed by a notary public. WITNESS: Notary Public I, ___________________________________, a notary public for the County of ______________ and the State of _______________________ do hereby certify that the above-named participant’s spouse appeared before me and acknowledged that he/she is the spouse of the participant, and that the above consent was signed by the participant’s spouse. Witness my hand and notary seal, this the ______ day of ____________, 20_____. Notary Public Signature My Commission Expires 4. Certification of marital statusI hereby certify that I am not now married and that there are no Plan benefits payable to a former spouse under a Qualified Domestic Relations Order. I hereby certify that I am not now married, however, there may be a reduction in my benefits as a result of a Qualified Domestic Relations order. Plan Participant Signature Date _ _ / _ _ / _ _ _ _Rev. 5/20/02 Page Directory: assets assets -> Northern territory of australia assets -> Number: caveat in the [Will/Will and Codicil/Estate of] assets -> Invitation for Bid Calact/mbta for Standard Floor and Low Floor Rural Duty Vehicles ifb no. 12-03 November 14, 2012 assets -> 12 Step Retreats For Everyone in Twelve Step Recovery Ratner Fellowship assets -> 12 Step Retreats For Everyone in Twelve Step Recovery Ratner Fellowship assets -> Sigaccess annual Report assets -> Central Government is expected to ask the seventh pay commission to consider merging 50% dearness allowance assets -> List of accessible executive records assets -> Emergency telephone numbers Call toll-free from anywhere in France Download 19.18 Kb. Share with your friends:
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