DOC 92-0047 Beneficiary Change of Designation
|[pic] |BENEFICIARY CHANGE OF DESIGNATION |
|I. PARTICIPANT INFORMATION |
|NAME: | |DATE OF BIRTH: | |(MM/DD/YYYY) |
|STREET ADDRESS: | |CITY: | |STATE: | |ZIP: | |
|TELEPHONE NUMBER: |( ) |SOCIAL SECURITY NUMBER: | |
|MARITAL STATUS: SINGLE MARRIED (NOTE: Spousal consent may be required. See below.) |
| |
|II. ACCOUNT INFORMATION |
|ACCOUNT NUMBER: | | |
| |
|III. BENEFICIARY INFORMATION |
| CHANGE OF BENEFICIARY: I hereby revoke all prior beneficiary designations and designate the following beneficiary(ies) for my account. |
| Check this box for per stirpes beneficiary designation. By selecting this option, you are negating the standard per capita beneficiary designation. Information |
|about beneficiaries may be required from the Executor of your estate or an authorized party. |
|The following shall be my beneficiary or beneficiaries of this IRA. If I designate more than one primary or contingent beneficiary, but do not specify the |
|percentages to which such beneficiary or beneficiaries is entitled, payment will be made to the surviving beneficiary or beneficiaries in equal shares. |
| |
|NOTE: For specific beneficiary provisions, please refer to the applicable sections of the Plan Document and the Disclosure Statement. |
|PRIMARY BENEFICIARIES *If more space is needed, attach and initial a separate sheet |
|NAME | |R| | |
| | |E| | |
| | |L| | |
| | |A| | |
| | |T| | |
| | |I| | |
| | |O| | |
| | |N| | |
| | |S| | |
| | |H| | |
| | |I| | |
| | |P| | |
| | |:| | |
|GENDER: | |PERCENTAGE: | | |GENDER: | |
| | | | | | | |
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|SOCIAL SECURITY NUMBER: | | | |SOCIAL SECURITY NUMBER: | | |
| |
|CONTINGENT BENEFICIARIES (Secondary beneficiaries will be paid only if all primary beneficiaries do not survive the participant) |
|*If more space is needed, attach and initial a separate sheet |
|NAME | |R| | |
| | |E| | |
| | |L| | |
| | |A| | |
| | |T| | |
| | |I| | |
| | |O| | |
| | |N| | |
| | |S| | |
| | |H| | |
| | |I| | |
| | |P| | |
| | |:| | |
|GENDER: | |PERCENTAGE: | | |GENDER: | |
| | | | | | | |
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| | | | | | | |
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|SOCIAL SECURITY NUMBER: | | | |SOCIAL SECURITY NUMBER: | | |
| |
|IV. SPOUSAL CONSENT (For use in community or marital property states including: AZ, CA, ID, LA, NV, NM, TX, WA, WI) |
|If you are married, reside in a community property or marital property state, and designate someone other than your spouse as your sole, primary beneficiary, your |
|spouse must sign this form in the space provided for spousal signature below. |
|I am the spouse of the above-named account holder. I acknowledge that I have received a fair and reasonable disclosure of my spouse’s property and financial |
|obligations. Due to the important tax consequences of giving up my interest in this IRA, SEP, or SIMPLE IRA, I have been advised to see a tax professional. I hereby |
|give the account holder any interest I have in the funds or property deposited in this IRA, SEP, or SIMPLE IRA and consent to the beneficiary designation(s) |
|indicated above. I assume full responsibility for any adverse consequences that may result. No tax or legal advice was given to me by NMIS, the Trustee or the |
|Custodian. |
|SIGNATURE OF SPOUSE: (Required in community or marital property states) | |DATE: | |
| |
|V. PARTICIPANT SIGNATURE |
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|SIGNATURE | |DATE: | |
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