Retirement Plan Beneficiary Designation Form
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1
2RETIREMENT PLAN
BENEFICIARY DESIGNATION FORM
_____________________________________________________________________________
PLAN NAME:
_____________________________________________________________________________
PARTICIPANT NAME:
A. PRIMARY BENEFICIARY: I hereby designate the following person or persons and/or trusts or trusts as beneficiaries of any
benefits that become payable from the Plan as a result of my death prior to the full commencement of my Plan benefits:
You can choose 1a. below; or you can choose 1b. and then from 2. through 6. below; or you can choose only from 2. through 6.
1a. [ ] 100 % to my SPOUSE
1b. [ ] The Qualified Preretirement Survivor Annuity (or alternative form of benefit distribution if consented to by my Spouse)
shall be payable to my surviving Spouse as required under the Plan. Any remaining benefits payable in the event of my
death prior to the full commencement of my benefits shall be payable as elected in 2, 3, 4, 5, and 6 below.
If either 1a. or 1b. is chosen, the consent of your spouse is NOT required. You must complete B. and C. below, but
NOT D., and your spouse should NOT complete E. If 1b. is chosen, you must complete one or more of 2. through 6. If
neither 1a. nor 1b. is chosen, you must complete B., C., and D. below, and your spouse must complete E.
2. [ ]
% to my SPOUSE, and
3. [ ]
% to my children per stirpes
4. [ ]
% to my children per capita
5. [ ] The following % to other beneficiaries:
% to Name: _________________________________________
Relationship: ________________________
% to Name: _________________________________________
Relationship: ________________________
% to Name: _________________________________________
Relationship: ________________________
6. [ ]
% to the following trust, created by me on the following date: _________________________________________.
Name of trust: ____________________________________________________________________________________.
The trustees for this trust are _________________________________________________________________________.
B. CONTINGENT BENEFICIARY: In the event a beneficiary designated above fails to survive me, I hereby designate the
following person or persons and/or trusts or trusts as contingent beneficiaries for that portion of benefits:
1. [ ]
% to my SPOUSE
2. [ ]
% to my children per stirpes
3. [ ]
% to my children per capita
4. [ ] The following % to other beneficiaries:
% to Name: _________________________________________
Relationship: ________________________
% to Name: _________________________________________
Relationship: ________________________
% to Name: _________________________________________
Relationship: ________________________
5. [ ]
% to the following trust, created by me on the following date: _________________________________________.
Name of trust: ____________________________________________________________________________________.
The trustees for this trust are _________________________________________________________________________.
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