Ira Designation Of Beneficiary Form
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1IRA DESIGNATION OF BENEFICIARY
_______________________________________________________
IRA NUMBER
STATE EMPLOYEES' CREDIT UNION
LGFCU
NCPAFCU
Type of IRA__________________(Traditional, Roth, CESA, SEP, Conduit, Beneficiary) Deposit Amount $__________________
TYPE OF IRA CONTRIBUTION _____ Prior Yr.______ Current Yr.______ SEP______ Transf._______ Rollover_______ Direct R/O
______New (Complete all information)
______Change (Verify demographic data)
Name:____________________________________________________________________________________________________________
Address:__________________________________________________________________________________________________________
Home Phone No. (
)_____________________ Work Phone No. (
)______________________ Dept. No.___________________
Social Security No._________________________________ Date of Birth: ______________________ Gender: ______ Female_______ Male
DESIGNATION OF BENEFICIARY(IES)
I designate the individual(s) named below as my primary and contingent beneficiary (ies) of this IRA. I revoke all prior IRA beneficiary designations,
if any, made by me. I understand that I may change or add beneficiaries at anytime by completing and delivering the proper form to the Custodian.
If any primary or contingent beneficiary dies before me, his or her interest and the interest of his or her heirs shall terminate completely, and the
percentage share of any remaining beneficiary(ies) shall be increased on a pro-rata basis.
The following individual(s) shall be my PRIMARY BENEFICIARY(IES):
Name: _____________________________________________________________________SSN: _________________________________
Address: _________________________________________________________________________________________________________
Date of Birth: _________________________ Share (%)_________________________ Relationship: ________________________________
Name: _____________________________________________________________________ SSN: _________________________________
Address: _________________________________________________________________________________________________________
Date of Birth: _________________________ Share (%)_________________________ Relationship: ________________________________
Name: _____________________________________________________________________ SSN:_________________________________
Address: _________________________________________________________________________________________________________
Date of Birth: _________________________ Share (%)_________________________ Relationship: ________________________________
CONTINGENT BENEFICIARY(IES) - If none of the Primary beneficiaries survive me, the following individual(s) shall be my beneficiay(ies)
Name: ____________________________________________________________________ SSN:__________________________________
Address: _________________________________________________________________________________________________________
Date of Birth: _______________________ Share (%)__________________________ Relationship: _________________________________
Name: ____________________________________________________________________ SSN: __________________________________
Address: _________________________________________________________________________________________________________
Date of Birth: _________________________ Share (%)_________________________ Relationship: ________________________________
IMPORTANT: Read before signing:
I understand the eligibility requirements for the type of IRA deposit I am making and I state that I do qualify to make the deposit. I have received a copy of the
Designation of Beneficiary form, 5305 Plan Agreement and Disclosure Statement. I understand the terms and conditions which apply to this Individual Retirement
Account are outlined in the 5305 Plan Agreement and Disclosure Statement. I agree to be bound by those terms and conditions. Within seven (7) days from the date
I open this IRA (except a CESA) I may revoke it without penalty by mailing or delivering a written notice to the Custodian.
I assume complete responsibility for:
1. Determining that I am eligible for an IRA each year I make a contribution.
2. Insuring that all contributions I make are within the limits set forth by the tax laws.
3. The tax consequences of any contribution (including rollover contributions) and distributions.
___________________________________________________________
____________________________________________________________
ACCOUNTHOLDER SIGNATURE / DATE
WITNESSED BY / DATE
CREDIT UNION USE
Employee (Print Name) _______________________________________ SECU Branch _________________________
SECU 465 (2/02)
White - Credit Union
Canary - Member
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