Retirement Plan Beneficiary Designation Form (Page 2 of 2) in pdf

C. AFFIRMATION AND ACKNOWLEDGMENT BY PARTICIPANT: All of my previous beneficiary designations, if any, are

null and void. I affirm that, to the best of my knowledge, there is no court order (other than a Qualified Domestic Relations Order)

that assigns any of my interest in the Plan to any other person. I hereby affirm that

[ ]

I am either not married or I have a court order recognizing my legal separation from my spouse; and if I was ever

previously married, I have a valid decree of divorce from all ex-spouses. I acknowledge that any designation made on

this form today may be invalidated upon my marriage, and agree to keep the Plan Administrator informed of any changes

to my marital status.

[ ]

I am presently legally married. I shall keep the Plan Administrator informed of any change to my marital status. Unless

my spouse is the only primary beneficiary, my spouse has completed the CONSENT portion of this form below. If I am

not yet age 35, I acknowledge that I will have to re-obtain the consent of my spouse to my naming a non-spouse primary

beneficiary when I turn age 35.

I acknowledge that I need to fill out a new beneficiary designation form to change any designations made on this form.

Participant's Signature: ____________________________________________________ Date: _________________________

You should NOT complete D. if you selected A.1a. or A.1b. above.

D. WAIVER OF PRE-RETIREMENT SURVIVOR ANNUITY - MARRIED PARTICIPANTS (optional)

I hereby waive, with spousal consent as provided below, the requirement that all or a portion of my benefits under the plan be

paid as an annuity over the life of my surviving spouse in the event of my death prior to retirement. If I am not yet age 35, I

acknowledge that I will have to again waive this requirement when I attain age 35 and, if then married, re-obtain the consent of

my spouse to my naming a non-spouse primary beneficiary when I turn age 35.

Participant's Signature: ____________________________________________________ Date: _________________________

Your spouse should NOT complete E. if you selected A.1a. or A.1b. above.

E. SPOUSAL CONSENT: Print name of spouse: _________________________________________________________

I hereby consent to the distribution of all (or the portion specified by my spouse on the Designation of Beneficiary form) of the

benefits payable from the Plan on account of the Participant’s death to the primary beneficiary named on the Designation of

Beneficiary form. I acknowledge that (1) the effect of my consent is to cause all or a portion of the Plan's death benefits to be paid

to a beneficiary other than me, (2) that the Participant's designation of a primary beneficiary other than me is not valid unless I

consent to it, and (3) that my consent is irrevocable unless the Participant subsequently revokes his or her waiver, in which event

my consent will again be required for the Participant to name a non-spouse beneficiary. If my spouse has waived the pre-

retirement surviving spouse annuity, I acknowledge that, but for my consent, all or a portion of my spouse's benefits would be

payable to me in the form of an annuity over my life, and I hereby irrevocably relinquish that right (however, should the

Participant revoke his or her waiver at any time, my consent will again subsequently be required to again waive this requirement).

Signature of Spouse: _____________________________________________________ Date:__________________________

Signature of Witness: ____________________________________________________ Date:__________________________

Print name of Witness:

_________________________________________________________________________________

[ ] Witness is a Plan Representative OR

[ ] Witness is a Notary Public (complete below):

State of __________________________

County of __________________________

My commission expires: __________________________________________________

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Retirement Plan Beneficiary Designation Form Page 2