EMPLOYEE INFORMATION CHANGE FORM

EMPLOYEE INFORMATION CHANGE FORM
Use this form to make name, marital status, or beneficiary changes in your existing ICMA Retirement Corporation 457 Deferred Compensation Plan,
401 Money Purchase Plan, or 401 Profit-Sharing Plan accounts.
For address changes, investment allocation changes or fund transfers, use VantageLink (www.icmarc.org) or VantageLine (1-800-669-7400).
If you wish to make a change to your payroll deduction, please use the 457 Deferred Compensation Plan Amount of Deferral Change Form or the 401
Amount of Contribution Change Form, depending upon your retirement plan type.
If this request requires your employer’s approval, submit the completed form for signature before forwarding it to ICMA-RC . (If you fax the form to
ICMA-RC, please do not mail the original.)
1
Employer Plan Number
Personal
Information
________________
(All information
in this section
must be
completed.)
Employer Plan Name
State
____________________________________________________________
______
Social Security Number
________ - ______ - ____________
Full Name of Participant
_________________________________________________ _________________________________________ ___
Last
First
M.I.
2
Make this change ONLY to the following plan(s):
(Note: For name
Employer Plan Number: _____________________ Employer Plan Name: ______________________________ State: ________
changes, you must
Employer Plan Number: _____________________ Employer Plan Name: ______________________________ State: ________
attach a copy of a
legal document (copy
Full New Name of Participant
of driver’s license,
etc.) and have
_________________________________________________ _________________________________________ ___
Employer approval.)
Last
First
M.I.
Name Change
3
Primary
Beneficiary
Change
(Please read important
beneficiary information
on the back of this form
before completing this
section.)
Complete this section ONLY if you want to change or add a primary beneficiary. Otherwise, if you do not complete this section, your primary
beneficiary information will be according to your previous designation.
The changes you indicate here will apply only to the plan account you indicated in section #1 above. If you have other ICMA-RC accounts with
other employers and you wish to make a primary beneficiary change to those accounts, please fill out one form for each employer account.
The primary beneficiary information you indicate here will supercede previously submitted information and will be used by ICMA-RC to
determine the primary beneficiaries entitled to all or a portion of your plan account.
Name of Primary Beneficiary(ies)
Date of Birth
Relationship to you
Social Security Number
❐
Spouse
❐
Other: __________________
❐
Spouse
❐
Other: __________________
% of benefit *
*Must total 100%. Use whole percentages only.
4
Contingent
Beneficiary
Change
(Please read important
beneficiary information
on the back of this form
before completing this
section.)
Complete this section ONLY if you want to change or add a contingent beneficiary. Otherwise, if you do not complete this section, your
contingent beneficiary information will be according to your previous designation.
The changes you indicate here will apply only to the plan account you indicated in section #1 above. If you have other ICMA-RC accounts with
other employers and you wish to make a contingent beneficiary change to those accounts, please fill out one form for each employer account.
The contingent beneficiary information you indicate here will supercede previously submitted information and will be used by ICMA-RC to
determine the contingent beneficiaries entitled to all or a portion of your plan account.
Name of Contingent Beneficiary(ies)
Date of Birth
Social Security Number
Relationship to you
❐
❐
Spouse
Spouse
❐
❐
% of benefit *
Other: __________________
Other: __________________
*Must total 100%. Use whole percentages only.
5
Marital Status
Change - Please
check one box.
Make this change ONLY to the following plan(s):
Employer Plan Number: _____________________
Employer Plan Name: _______________________________ State: ________
Employer Plan Number: _____________________
Employer Plan Name: _______________________________ State: ________
New Marital Status:
6
Authorizations
❐
Married
❐
Single
____________________________________________________________
Participant Signature
Date
_______________________________________________________
Employer Signature (if required)
Date
____________________________________________________________
Spousal Signature
Date
All 401 plans with marital rights require the spouse as
100% primary beneficiary, unless your spouse waives this
right by signing here.
ICMA Retirement Corporation • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 1-800-669-7400 • En Español 1-800-669-8216 • www.icmarc.org • Fax 202-682-6439
Important Beneficiary Information
To ensure that any assets you have remaining in your account at your death are distributed according to
your wishes, it is important that you provide as much information as possible about each of your beneficiaries. If we cannot locate your beneficiaries upon your death, your assets will be disbursed to your estate.
The IRS has certain rules governing disbursement of funds to beneficiaries. For example, some plans
require that a spouse be named primary beneficiary unless he/she waives his/her rights. These rules are
outlined in your employer's plan and in ICMA-RC's Participant and Beneficiary Withdrawal Packets. Please
be sure to review this information thoroughly before designating beneficiaries on this form.
If you choose more than one beneficiary without indicating percentages, or if the percentages you allocate
to your beneficiaries combined do not total 100%, we will allocate equal percentages totaling 100%.
Primary Beneficiary(ies)
You may designate one or more persons to receive your assets upon your death. Be sure to use only whole
percentages.
Contingent Beneficiary(ies)
If none of your primary beneficiaries are living upon your death, your assets will be distributed to your
contingent beneficiary(ies). You may specify one or several persons. Be sure to use only whole percentages.
If there is not enough space to add your beneficiaries, you may attach a separate sheet if necessary. Please
check the appropriate box to indicate which type(s) of beneficiary you are changing, and write “see attached
sheet” in the box(es) under “Name of Beneficiary”.
Note: If a Social Security Number is not provided for beneficiaries, and/or ICMA-RC cannot locate the named
beneficiaries, the account balance will be paid to your estate.
SPECIAL CERTIFICATION FOR PARTICIPANTS IN COMMUNITY PROPERTY STATES
If you are married and live in a Community Property state, you must generally name your spouse as your
beneficiary, unless your spouse waives this right. ICMA-RC cannot be responsible for an employee's failure
to properly designate a beneficiary in accordance with state law requirements and the employee’s failure to
provide the certification required by this enrollment process. Please be advised that failure to meet state law
requirements with respect to your beneficiary designation may result in your beneficiary designation being
invalid, and the payment of benefits to someone other than your designated beneficiary. If you choose to
name a beneficiary that is not your spouse, you and your spouse will need to complete the Community
Property Spousal Waiver form. Contact 1-800-669-7400 for more information and to request the waiver
form.