SEI IRA Cover

[Pages:4]SEI Account Number:

IRA Beneficiary Designation Form

Instructions:

Complete all applicable sections of this form to designate a beneficiary to your SEI Private Trust Company ("SPTC") Individual Retirement Account ("IRA"). In order for a beneficiary request to be considered complete, all 4 pages must be submitted. Altered forms will not be accepted.

Forward completed form to: SEI Private Trust Company Attention: Advisor Network (Service Team) P.O. Box 1098 Oaks, PA 19456-9907 OR Fax: 610-676-1021

IRA Owner Information

IRA Owner's Name Taxpayer Identification Number

Advisor Information

Date of Birth

Advisor's Name

Advisor's Phone Number

Type of Request

Initial Designation(s), OR Replace Existing Beneficiary Designation(s)

(Restate all beneficiary designations)

IRA Information Traditional IRA Roth IRA SEP-IRA

Inherited IRA Inherited Roth IRA SIMPLE IRA

Beneficiary Designation Choices

SPTC is willing to accept Per Stirpes, Per Capita and All My Children beneficiary designations. The following is a brief description of these designations. Please be advised that SPTC offers no advice or direction through the offering of this form as it is intended to capture your beneficiary request only and suggests that the IRA owner completing this form seek the advice of your Registered Investment Advisor (RIA) or an estate planning professional. SPTC will not be responsible for locating or contacting beneficiaries or their issue.

Standard Designation means that upon your death, the assets held within your SPTC IRA will be distributed to your selected beneficiary(ies). In the event that said beneficiary(ies) predecease(s) you, the beneficiary(ies)'s percentage will be divided, on a pro-rata basis, among the remaining primary beneficiary(ies), if any, or if there are no surviving primary beneficiaries, among the contingent beneficiary(ies) on this form.

Per Stirpes means that upon your death, the assets held within your SPTC IRA will be distributed to your selected beneficiary(ies) as normal. In the event that said beneficiary(ies) predeceases the account owner, his or her percentage is passed on, equally, to his / her issue. If he or she has no surviving issue, the funds will be divided among the remaining beneficiaries on a pro-rata basis. Per Stirpes and Per Capita MAY NOT be used within the same level of designation (i.e. one primary beneficiary Per Capita, one Per Stirpes).

Per Capita means that upon your death, the assets held within your SPTC IRA will be distributed to your selected beneficiary(ies) as normal. In the event that said beneficiary(ies) predeceases the account owner, his or her share is divided equally among both his or her issue, as primary beneficiary(ies), and the remaining primary beneficiary(ies) named by you. If he or she has no surviving issue, the funds will be divided among the remaining beneficiaries on a pro-rata basis. Per Stirpes and Per Capita MAY NOT be used within the same level of designation (i.e. one primary beneficiary Per Capita, one Per Stirpes).

All My Children means that upon your death, the assets held within your SPTC IRA will be distributed to your surviving natural or adoptive children. Step children are not eligible with this designation. SPTC cannot honor any exclusions when using the `All My Children' designation. Should there be no living children at the time of the IRA owner's death, the assets will pass to the contingent beneficiaries, if named, or to the estate if there are no contingent beneficiaries. It is not necessary to list the names of each individual child.

Form ID BA1

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Continued

IRA Beneficiary Designation Form

Page 2

Primary Beneficiary Designation(s)

Upon the death of the IRA owner, SPTC will transfer ownership of the account, in the percentages specified, to the beneficiary(ies) listed below once proper notification of death has been received and proof of inheritance tax payment (if applicable) has been provided. The election made below supercedes any previous election and is not valid unless signed by the IRA owner. Per Stirpes and Per Capita MAY NOT be used within the same level of designation (i.e. one primary beneficiary Per Capita, one Per Stirpes). Beneficiary percentages must equal 100% or the form will be rejected. If additional space is required, please adhere to the following requirements for attachments to the IRA Beneficiary Designation Form.

In order for an attachment to an IRA Beneficiary Designation Form to be accepted, it must meet the following requirements: I The attachment must be submitted with all four pages of the IRA Beneficiary Designation Form I All beneficiaries, primary and contingent, must be restated on the attachment I The attachment must include the SPTC account number and must be signed and dated by the IRA owner

Attachments will be reviewed by SPTC and the advisor will be notified if the beneficiary designation is not acceptable.

Primary Beneficiary Designation(s):

1.

Beneficiary Name (First, Last)

%

Designation Choice (e.g., Standard, Per Stirpes, etc.)

Share

Relationship

Taxpayer Identification Number

Date of Birth

2.

Beneficiary Name (First, Last)

Designation Choice (e.g., Standard, Per Stirpes, etc.)

%

Share

Relationship

Taxpayer Identification Number

Date of Birth

3.

Beneficiary Name (First, Last)

%

Designation Choice (e.g., Standard, Per Stirpes, etc.)

Share

Relationship

Taxpayer Identification Number

Date of Birth

4.

Beneficiary Name (First, Last)

%

Designation Choice (e.g., Standard, Per Stirpes, etc.)

Share

Relationship

Taxpayer Identification Number

Date of Birth

5.

Beneficiary Name (First, Last)

%

Designation Choice (e.g., Standard, Per Stirpes, etc.)

Share

Relationship

Taxpayer Identification Number

Date of Birth

6.

Beneficiary Name (First, Last)

%

Designation Choice (e.g., Standard, Per Stirpes, etc.)

Share

Relationship

Taxpayer Identification Number

Date of Birth

7.

Beneficiary Name (First, Last)

Relationship

Taxpayer Identification Number

Designation Choice (e.g., Standard, Per Stirpes, etc.) Date of Birth

%

Share

%

Total Share (Must equal 100%)

Form ID BA1

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IRA Beneficiary Designation Form

SEI Account Number:

Page 3

Contingent Beneficiary Information

SPTC will transfer ownership of your investment account to the contingent beneficiary(ies) listed below in the event the primary beneficiary(ies) predeceases the IRA owner. If there are no surviving contingent beneficiaries at the time of your death, then SPTC will transfer ownership of your account to your estate. If additional space is required, please adhere to the following requirements for attachments to the IRA Beneficiary Designation Form.

In order for an attachment to an IRA Beneficiary Designation Form to be accepted, it must meet the following requirements: I The attachment must be submitted with all four pages of the IRA Beneficiary Designation Form I All beneficiaries, primary and contingent, must be restated on the attachment I The attachment must include the SPTC account number and must be signed and dated by the IRA owner

Attachments will be reviewed by SPTC and the advisor will be notified if the beneficiary designation is not acceptable.

Contingent Beneficiary Designation(s):

1.

Beneficiary Name (First, Last)

%

Designation Choice (e.g., Standard, Per Stirpes, etc.)

Share

Relationship

Taxpayer Identification Number

Date of Birth

2.

Beneficiary Name (First, Last)

%

Designation Choice (e.g., Standard, Per Stirpes, etc.)

Share

Relationship

Taxpayer Identification Number

Date of Birth

3.

Beneficiary Name (First, Last)

%

Designation Choice (e.g., Standard, Per Stirpes, etc.)

Share

Relationship

Taxpayer Identification Number

Date of Birth

4.

Beneficiary Name (First, Last)

%

Designation Choice (e.g., Standard, Per Stirpes, etc.)

Share

Relationship

Taxpayer Identification Number

Date of Birth

5.

Beneficiary Name (First, Last)

%

Designation Choice (e.g., Standard, Per Stirpes, etc.)

Share

Relationship

Taxpayer Identification Number

Date of Birth

6.

Beneficiary Name (First, Last)

%

Designation Choice (e.g., Standard, Per Stirpes, etc.)

Share

Relationship

Taxpayer Identification Number

Date of Birth

7.

Beneficiary Name (First, Last)

Relationship

Taxpayer Identification Number

Designation Choice (e.g., Standard, Per Stirpes, etc.) Date of Birth

%

Share

%

Total Share (Must equal 100%)

Form ID BA1

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Continued

IRA Beneficiary Designation Form

Page 4

Spousal Consent

Signature

This section must be completed if the residence of the IRA owner is located in a community or marital property state and the spouse is not named as 100% primary beneficiary. Due to the important tax consequences of giving up one's community property interest, individuals signing this section should consult with a Tax or Legal Advisor.

Current Marital Status:

I Am Not Married. I understand that if I become married in the future, I must complete a new IRA Beneficiary Designation Form.

I Am Married. I understand that if I choose to designate a primary beneficiary other than my Spouse, my Spouse must sign below.

I am the Spouse of the above-named IRA owner. 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, I have been advised to see a tax professional.

I hereby give the IRA owner any interest I have in the funds or property deposited in this IRA to the extent necessary to carry out the terms of this designation and consent to the beneficiary designation(s) indicated above. I understand that if the IRA owner later changes a beneficiary of this IRA in a way that limits my legal rights, I must be allowed to review the IRA Beneficiary Designation Form for the purpose of providing a new consent. I assume full responsibility for any adverse consequences that may result. No tax or legal advice was given to me by SPTC.

Note: SPTC makes no suggestion and offers no advice as to whether these beneficiary designations are the proper estate planning technique for you. This decision should only be made with the assistance of your Registered Investment Advisor (RIA) or estate planning specialist.

I agree to indemnify and hold harmless SPTC, its officers, directors, employees and affiliates from any and all claims arising out of or from any provisions held in the IRA, by will or in any other written form, that are in any way conflicting with the information provided on this form.

I understand that upon my death and with proper documen tation including, but not limited to, a certified copy of my death certificate, an inheritance tax payment receipt (or waiver) if required by law, a signed Account Application, SPTC will immediately transfer ownership of the account to the beneficiary(ies), or their issue, as designated herein.

In the event that my beneficiary should want to remove the assets from SPTC, I understand that a properly completed IRS Form W-9 will be required for tax reporting purposes.

I further agree and understand that for any future modifications to be valid they must be received by SPTC, on the applicable valid, signed IRA Beneficiary Designation Form, before such time as my death.

By signing the Form below I agree that the beneficiary designation(s) on the second and third pages override any previous designation(s) made by me. indemnify and hold harmless SPTC from any and all damages, including legal counsel, in the event that these designations are contested and legal counsel is sought by SPTC.

Name of Spouse Signature of Spouse

Spouse's State of Residence Date

Name of IRA Owner Signature of IRA Owner

Date

Form ID BA1

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