Form Dc-770-0113 - Nationwide Beneficiary Change Form
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1
2Beneficiary Change Form
Social Security Number
Employer Name
State
Participant
Information
(please print)
Last Name
First Name
Middle Initial
Street Address
City
State
Zip Code
Contact Phone Number
Email Address
Date of Birth
Indicate the names of the beneficiaries, their Social Security numbers, the split you’d like each one of them to
Beneficiary
receive, their address, their dates of birth, and their telephone number. If the percentage is not indicated, the pay-
Designation
ments will be distributed equally in whole percentages. This beneficiary designation applies to all funding options
(including life insurance) unless otherwise noted. For payout purposes, the Plan Administrator will establish sub-
accounts and not separate accounts for beneficiaries, which in the case of multiple beneficiaries may require that
required minimum distributions be based on the life expectancy of the oldest beneficiary. Split must be in whole per-
centages.
r
Check here if this is a change of beneficiary. (Beneficiaries listed below replace any prior designation).
PLEASE NOTE: Percentage split must total 100% and must be in whole percentages.
If additional space for beneficiaries is required, please complete and attach additional sheets with all the
r
required ifnormation below then mark this box:
Beneficiary Name
Social Security Number
%Split
r Primary
r Contingent
Address
Date of Birth
Phone #
Beneficiary Name
Social Security Number
%Split
r Primary
r Contingent
Address
Date of Birth
Phone #
This designation supercedes any prior beneficiary designation and shall become effective on the date accepted by
Authorization
the Plan as listed below prior to my death. Any benefits payable at my death shall be paid in equal shares unless
otherwise specified. My death benefits will be paid first to my Primary Beneficiaries. If some of my Primary
Beneficiaries predecease me, then my death benefit will be paid to the remaining Primary Beneficiaries. Contingent
Beneficiaries will only receive benefits if no Primary Beneficiary survives me. If no beneficiary designation is on file,
benefits will be paid pursuant to the sequence set forth in the Plan Document.
Participant Signature
Date
Witness Signature
Date
(NOTE: Witness cannot be a named beneficiary)
Witness Name & Address
Witness City, State, and Zip Code
Mail completed form to: Nationwide Retirement Solutions
P.O. Box 182797
Columbus, Ohio 43218-2797
DC-770-0113
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