IRA Change of Beneficiary Form

Reset Form
IRA Change of Beneficiary Form
PO Box 2760  Omaha, NE 68103-2760
Fax: 866-468-6268
If wanting to designate beneficiaries for a non-IRA account, please submit a Transfer on Death Agreement Beneficiary (TOD) Agreement
TDA 097 located within the forms library: https://www.tdameritrade.com/form-library
1. ACCOUNT INFORMATION
Account Number:
Full Legal Name:
Date of Birth:
(MM-DD-YYYY) ____ ____—____ ____—____ ____ ____ ____
Marital Status:
U.S. Social Security Number:
(SSN)
____ ____ ____—____ ____—____ ____ ____ ____
N Married N Single N Divorced N Widowed
2. DESIGNATION OF BENEFICIARY (All Fields Required)
You must designate at least one primary beneficiary. If you select co-primary beneficiaries, indicate the percentage of your account you are
designating to each. If a primary beneficiary dies prior to the Account Owner, the remaining portion shall be payable proportionately to any surviving
primary beneficiaries. You may also designate contingent beneficiaries in the event that your primary beneficiaries do not outlive you. In the event
that TD Ameritrade Clearing, Inc. is unable to identify the beneficiaries from the documents provided, the Custodial Agreement will control.
State IRA and trust laws may vary as to the legality of IRA beneficiaries naming beneficiaries to their inherited account. Please consult a
qualified tax advisor or attorney regarding the applicable IRA and trust laws for your state of residence. TD Ameritrade Clearing, Inc. is not liable
for any tax or legal consequences as a result of designating a beneficiary on an inherited IRA.
Percentages must total 100% for all primary beneficiaries and 100% for all contingent beneficiaries. If percentages are not indicated, then they will
be deemed equal shares. Further, when securities cannot be evenly distributed, or there are unclaimed securities, the Account Owner requests
that such securities be liquidated and any proceeds from the liquidation be distributed in the percentages requested to the named Beneficiaries.
Subject to the condition(s) set forth in this section, I designate the following as the beneficiary(ies) of my IRA:
DESIGNATE YOUR PRIMARY BENEFICIARY(IES)
Primary Share %
Beneficiary’s Name:
Beneficiary Is: M an Individual M a Trust
M Other (Custodianship, Charity, Corporation, etc.)
Date of Birth:
SSN:
____ ____—____ ____— ____ ____ ____ ____
____ ____ ____—____ ____— ____ ____ ____ ____
Relationship:
Trustee Names (for Beneficiaries who are trusts only):
Date of Creation:
Entity’s Name (for non-Individual Beneficiaries only):
Authorized Officer Names (for corporations and other organizations only):
Beneficiary’s Name:
Beneficiary Is: M
an Individual M a Trust
M Other (Custodianship, Charity, Corporation, etc.)
Date of Birth:
SSN:
____ ____—____ ____— ____ ____ ____ ____
Primary Share %
____ ____—____ ____— ____ ____ ____ ____
____ ____ ____—____ ____— ____ ____ ____ ____
Relationship:
Trustee Names (for Beneficiaries who are trusts only):
Date of Creation:
____ ____—____ ____— ____ ____ ____ ____
Primary Share %
Entity’s Name (for non-Individual Beneficiaries only):
Authorized Officer Names (for corporations and other organizations only):
Beneficiary’s Name:
Beneficiary Is: M
an Individual M a Trust
M Other (Custodianship, Charity, Corporation, etc.)
Date of Birth:
SSN:
____ ____—____ ____— ____ ____ ____ ____
____ ____ ____—____ ____— ____ ____ ____ ____
Relationship:
Trustee Names (for Beneficiaries who are trusts only):
Date of Creation:
____ ____—____ ____— ____ ____ ____ ____
Entity’s Name (for non-Individual Beneficiaries only):
*TDA104*
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Authorized Officer Names (for corporations and other organizations only):
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Primary Share %
Beneficiary’s Name:
Beneficiary Is: M an Individual M a Trust
M Other (Custodianship, Charity, Corporation, etc.)
Date of Birth:
SSN:
____ ____—____ ____— ____ ____ ____ ____
____ ____ ____—____ ____— ____ ____ ____ ____
Relationship:
Trustee Names (for Beneficiaries who are trusts only):
Date of Creation:
____ ____—____ ____— ____ ____ ____ ____
Entity’s Name (for non-Individual Beneficiaries only):
Authorized Officer Names (for corporations and other organizations only):
DESIGNATE YOUR CONTINGENT BENEFICIARY(IES)
Contingent Share %
Beneficiary’s Name:
Beneficiary Is: M an Individual M a Trust
M Other (Custodianship, Charity, Corporation, etc.)
Date of Birth:
SSN:
____ ____—____ ____— ____ ____ ____ ____
____ ____ ____—____ ____— ____ ____ ____ ____
Relationship:
Trustee Names (for Beneficiaries who are trusts only):
Date of Creation:
Entity’s Name (for non-Individual Beneficiaries only):
Authorized Officer Names (for corporations and other organizations only):
Beneficiary’s Name:
Beneficiary Is: M
an Individual M a Trust
M Other (Custodianship, Charity, Corporation, etc.)
Date of Birth:
SSN:
____ ____—____ ____— ____ ____ ____ ____
Contingent Share %
____ ____—____ ____— ____ ____ ____ ____
____ ____ ____—____ ____— ____ ____ ____ ____
Relationship:
Trustee Names (for Beneficiaries who are trusts only):
Date of Creation:
Entity’s Name (for non-Individual Beneficiaries only):
Authorized Officer Names (for corporations and other organizations only):
Beneficiary’s Name:
Beneficiary Is: M
an Individual M a Trust
M Other (Custodianship, Charity, Corporation, etc.)
Date of Birth:
SSN:
____ ____—____ ____— ____ ____ ____ ____
Contingent Share %
____ ____—____ ____— ____ ____ ____ ____
____ ____ ____—____ ____— ____ ____ ____ ____
Relationship:
Trustee Names (for Beneficiaries who are trusts only):
Date of Creation:
____ ____—____ ____— ____ ____ ____ ____
Contingent Share %
Entity’s Name (for non-Individual Beneficiaries only):
Authorized Officer Names (for corporations and other organizations only):
Beneficiary’s Name:
Beneficiary Is: M
an Individual M a Trust
M Other (Custodianship, Charity, Corporation, etc.)
Date of Birth:
SSN:
____ ____—____ ____— ____ ____ ____ ____
____ ____ ____—____ ____— ____ ____ ____ ____
Relationship:
Trustee Names (for Beneficiaries who are trusts only):
Date of Creation:
____ ____—____ ____— ____ ____ ____ ____
Entity’s Name (for non-Individual Beneficiaries only):
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Authorized Officer Names (for corporations and other organizations only):
TDA 104 F 10/15
This section should be reviewed if the residence of the account owner is located in a community property or marital property state
and the account owner is married and is not naming their spouse as sole primary beneficiary. Due to the important tax consequences
of giving up one’s community property interest, individuals signing this section should consult with a tax or legal advisor.
I am the spouse of the account owner. I consent to the named beneficiaries other than or in addition to myself. I assume full responsibility for any adverse consequences that may result. No tax or legal advice was given to me by the Custodian.
✗
Date:
Signature of Spouse:
____ ____—____ ____—____ ____ ____ ____
If you live in a community property state and your spouse is not a 100% beneficiary, this form will need to be notarized.
NOTARY PUBLIC
County of: _____________________________________________ )
) ss
State of: _______________________________________________)
Subscribed to and sworn to before me this _________________________ day of __________________________ , ____________ .
Notary Public: ____________________________________________________________________
[SEAL]
3. SIGNATURE
The undersigned Account Owner hereby states that all previous designation(s) of beneficiary(ies), with respect to the above-designated IRA,
are hereby revoked. Account Owner understands that this Change of Beneficiary will be effective on the date of receipt by TD Ameritrade
Clearing, Inc., and that, upon any change of beneficiary, the right of all previously designated beneficiaries to receive benefit under this account
shall cease. Account Owner retains the right to revoke this designation of beneficiary and to designate a new beneficiary at any time by written
communication to: TD Ameritrade, Inc., 200 S 108th Ave, Omaha, NE 68154.
Please submit along with this form a copy of a current government issued photo ID containing your signature or you may submit the
form with a TD Ameritrade branch stamp.
✗
Date:
Account Owner’s Signature:
____ ____—____ ____—____ ____ ____ ____
Original signature required; electronic signatures and/or signature fonts are not authorized.
Investment Products: Not FDIC Insured * No Bank Guarantee * May Lose Value
TD Ameritrade, Inc. and TD Ameritrade Clearing, Inc., members FINRA/SIPC. TD Ameritrade is a trademark jointly owned by
TD Ameritrade IP Company, Inc. and The Toronto-Dominion Bank. © 2015 TD Ameritrade IP Company, Inc. All rights reserved. Used with permission.
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