ICMA-RC Beneficiary Designation Form

BENEFICIARY DESIGNATION FORM INSTRUCTIONS
Please note: You only need to complete this form if your beneficiary designation requires
spousal consent. See Section 4 to see if this applies to you.
In the event of your death, your designated beneficiary(ies) will be entitled to any assets remaining in your account. Please provide all of the requested information for each beneficiary – this information will help ICMARC locate your beneficiaries if necessary. You can always update your beneficiary information online by
following the instructions below.
Designating beneficiaries for your account is important:
• Your designation helps to ensure assets will be paid out according to your wishes and will not be subject
to the potential costs and delays of probate, as well as creditor claims. If all of your primary beneficiaries
are no longer living at the time of your death, benefits will be paid to your contingent beneficiaries.
• Your beneficiaries may receive more tax advantages.
Percent of Benefit Information – If you provide percentages that do not total 100%, or provide non-whole
numbers, your designations will be invalid. However, if no percentages are provided for any beneficiary designations, the benefit will be allocated equally among all beneficiaries.
Trust Beneficiaries – If you name a trust as your primary or contingent beneficiary, you must submit a complete copy of your entire trust document with this form.
Update Beneficiary Information Online
• Log in to ICMA-RC’s Account Access at www.icmarc.org
• Go to the Manage My Account tab and click the My Profile link
• Click the Beneficiaries link
• Click the Update Beneficiaries button and enter your beneficiary information
Married Participants
If you do not designate your spouse as the primary beneficiary for your account, your spouse may be required
to consent to your beneficiary designation. Please review the additional information in the Spousal Consent
section (Section 4) of the form.
• VantageTrust Retirement IncomeAdvantage Fund Investors – To Lock-In and receive spousal benefits from the Fund, your spouse must be designated as the primary beneficiary for 100% of your account, both at the time you Lock-In the benefit and at the time of your death. Additional information
is available in the VantageTrust Retirement IncomeAdvantage Fund Important Considerations document,
available online or by contacting ICMA-RC at 800-669-7400.
Fax or Mail the Completed Form to ICMA-RC
If you fax the form to ICMA-RC, please do not also send it to us by mail. Page 2 is only needed if your beneficiary designation requires spousal consent.
Mail:
Fax: ICMA-RC ICMA-RC
ATTN: Workflow Management Team ATTN: Workflow Management Team 202-682-6439 P.O. Box 96220
Washington, DC 20090-6220
Please keep a copy of completed form for your records.
FRM570-005-0213-6291-385
BENEFICIARY DESIGNATION FORM - PAGE 1 OF 2
1)Use this form to designate beneficiaries for your employer-sponsored retirement plan with ICMA-RC.
2)You only need to complete this form if your beneficiary designation requires spousal consent. Otherwise, you may update your beneficiary
information quickly and securely via Account Access at www.icmarc.org.
- Spousal Consent – If you are married and do not designate your spouse as primary beneficiary for your account, your spouse may be required to
consent to your designation by signing Section 4 of this form. Please refer to Section 4 for additional information.
1. PERSONAL INFORMATION
Employer Plan Number
Employer Plan Name
___ ___ ___ ___ ___ ___
___________________________________________________________________
Social Security Number (for tax-reporting purposes)
Date of Birth
___ ___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ / ___ ___ /___ ___ ___ ___
Month
Day
Year
Full Name of Participant
Email Address
________________________________________________________________________________
Last
First
M.I.
____________________________________
2. BENEFICIARY DESIGNATION
•
•
•
•
Update your beneficiary designations and/or designate additional beneficiaries at any time via Account Access at www.icmarc.org.
Your “Primary” beneficiary(ies) must total 100% and your “Contingent” beneficiary(ies) if applicable must also total 100%.
Use whole percentages only (e.g., 50%, not 33.33% or 33 1/3 %).
Check one “Beneficiary Type” and one “Relationship” for each beneficiary. Failure to do so may result in your designation being invalid.
Beneficiary Type:
p
ü Primary
Relationship (Check One):
p Spouse p Non-Spouse p Trust* p Charity p Estate
________________________________________________________
Name
Beneficiary Type (Check One):
p Primary p Contingent
Relationship (Check One):
p Primary p Contingent
Relationship (Check One):
p Primary p Contingent
Relationship (Check One):
p Primary p Contingent
Relationship (Check One):
__ __ __%
% of Benefit
(whole % only)
__ __ /__ __ /__ __ __ __
Date of Birth
__ __ - __ __ - __ __ __ __
Social Security Number
__ __ __%
% of Benefit
(whole % only)
__ __ /__ __ /__ __ __ __
Date of Birth
__ __ - __ __ - __ __ __ __
Social Security Number
__ __ __%
% of Benefit (whole % only)
p Spouse p Non-Spouse p Trust* p Charity p Estate
________________________________________________________
Name
Beneficiary Type (Check One):
__ __ - __ __ - __ __ __ __
Social Security Number
p Spouse p Non-Spouse p Trust* p Charity p Estate
________________________________________________________
Name
Beneficiary Type (Check One):
Date of Birth
p Spouse p Non-Spouse p Trust* p Charity p Estate
________________________________________________________
Name
Beneficiary Type (Check One):
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
Date of Birth
__ __ - __ __ - __ __ __ __
Social Security Number
__ __ __%
% of Benefit
(whole % only)
p Spouse p Non-Spouse p Trust* p Charity p Estate
________________________________________________________
Name
__ __ /__ __ /__ __ __ __
Date of Birth
__ __ - __ __ - __ __ __ __
Social Security Number
__ __ __%
% of Benefit
(whole % only)
*Trust Beneficiaries – You must submit a copy of your entire trust document with this form.
Designate additional beneficiaries online after your account is established, or write “see attached sheet” and attach and sign a separate piece of paper with your name, plan number, Social Security number, and the additional
beneficiary information.
3. SIGNATURES
Participant Signature ____ ___/____ ____ /____ ____ ____ ____
Month
Day
Year
_________________________________________________________
Employer Signature (if required)
____ ___/____ ____ /____ ____ ____ ____
Month
Day
Year
________________________________________________________________ ICMA-RC • Attn: Workflow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400 • En Español 800-669-8216 • www.icmarc.org • Fax 202-682-6439
FRM570-005-0213-6291-385
REV/7/2014
BENEFICIARY DESIGNATION FORM - PAGE 2 OF 2
Employer Plan Number
Social Security Number
Full Name of Participant (Please Print)
__ __ __ __ __ __
__ __ __ - __ __ - __ __ __ __
__________________________________________________________________________
Last
First
M.I.
4. SPOUSAL CONSENT
Community Property States (AZ, CA, ID, LA, NV, NM, TX, WA, or WI) – A participant living in a community property state must designate his/
her spouse as the primary beneficiary for at least 50% of the account, unless the spouse waives his/her right by consenting to an alternative beneficiary
designation. By signing below, you (the participant’s spouse) are consenting to the benefit percentage specified below and the participant’s beneficiary
designation(s) on page 1 of this form.
401 Defined Contribution Plans – Many 401 plans require that a married participant designate his/her spouse as the primary beneficiary for 100% of
the account, unless the spouse waives his/her right by consenting to an alternative beneficiary designation. By signing below, you are consenting to the
benefit percentage specified below and the participant’s beneficiary designation(s) on page 1 of this form.
State Law: ICMA-RC makes this form available as a means of helping participants satisfy state law requirements relating to beneficiary designations.
ICMA-RC is not responsible for a participant’s failure to properly designate a beneficiary in accordance with state law. Failure to satisfy state law
requirements may result in a beneficiary designation being invalidated, and benefits being paid in accordance with state law.
Spousal Consent and Acknowledgement: By signing below, I agree to waive my beneficiary rights in my spouse’s retirement plan account, and consent to
1) receive the benefit percentage specified below, and 2) the beneficiary designation on page 1 of this form. I understand this waiver will result in some or
all of my spouse’s death benefit being paid to someone other than me. I further understand that future changes to my spouse’s beneficiary designations will
not be valid unless I consent to any such changes.
Spouse Benefit Percentage (whole % only): ___ ___ ___ % (This percentage should match the percentage, if any, specified on page 1 of the form. Write “0” if applicable.)
_________________________________________________________
Spouse Signature
____ ___/____ ____ /____ ____ ____ ____ Month
Day
Year
_________________________________________________________
Name (Please Print)
5. WITNESS
• For 457 deferred compensation plans, a Notary Public is required to witness the spouse signature for the above spousal consent to be valid in a community property state.
• For 401 defined contribution plans, the above spousal consent must be witnessed by either an authorized employer plan representative or a Notary
Public.
Employer’s Plan Representative
__________________________________________________
Employer Signature
__________________________________________________
Name (Please Print)
__________________________________________________
Title
____ ___/____ ____ /____ ____ ____ ____ Month
Day
Year
Notary Public
Subscribed and sworn before me this ______ day of ______________________ (month), 20____
_________________________________________________
Notary Public’s Signature
Notary Public SEAL ___________________________
My commission expires _____________
ICMA-RC • Attn: Workflow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400 • En Español 800-669-8216 • www.icmarc.org • Fax 202-682-6439
FRM570-005-0213-6291-385
REV/7/2014