Beneficiary Designation/ Change Form

Mailing Address:
P.O. Box 8963
Wilmington, DE 19899-8963
800-209-9010 Fax: 302-999-9554
[email protected]
Beneficiary Designation/
Change Form
I. Participant Information (Please print or type)
Plan Name
Brokerage Firm & Account Number
Participant Name
Social Security Number
Street Address
Daytime Phone Number
City
State
ZIP Code
II. Beneficiary Designations
I hereby designate the following individuals as primary and contingent beneficiaries of my accumulated benefits which
will be paid by reason of my death under the provisions of the plan. The trustee shall pay all accumulated benefits
under the plan by reason of death to the primary beneficiary(ies), and if no primary beneficiary(ies) shall survive, then to
the spouse (if any) or to the estate of the Participant. If more than one beneficiary is designated, such beneficiaries
share equally unless otherwise specified. The trustee shall make payment in accordance with the most recent
beneficiary data sheet, which is on file with the plan sponsor. This beneficiary designation will supercede any and all
previous beneficiary designations. The right to revoke or change any beneficiary designation is hereby reserved. All
prior beneficiary designations (if any) are hereby revoked. Note: Please check the appropriate Primary or
Contingent box for each beneficiary. Percentages must total 100.
Primary
Contingent
Name
Social Security Number
Date of Birth
Allocation
Relationship
Phone Number
City
State
%
Street Address
Primary
Contingent
Name
ZIP Code
Social Security Number
Date of Birth
Allocation
Relationship
Phone Number
City
State
%
Street Address
Primary
Contingent
Name
ZIP Code
Social Security Number
Date of Birth
Allocation
Relationship
Phone Number
City
State
%
Street Address
Primary
Contingent
Name
ZIP Code
Social Security Number
Date of Birth
Allocation
Relationship
Phone Number
City
State
%
Street Address
ZIP Code
Delaware Charter Guarantee & Trust Company d/b/a Principal Trust Company
TR301-1
Page 1 of 3
12/2007
Primary
Contingent
Name
Social Security Number
Date of Birth
Allocation
Relationship
Phone Number
City
State
%
Street Address
Primary
Contingent
Name
ZIP Code
Social Security Number
Date of Birth
Allocation
Relationship
Phone Number
City
State
%
Street Address
ZIP Code
III. Participant Certification of Marital Status
I am single
I am married
I am married and have no knowledge of the whereabouts of my spouse
IV.
Spouse’s Consent and Waiver
Complete this section only if someone other than spouse is listed as Primary Beneficiary
I hereby consent to the foregoing beneficiary designation by my spouse, naming someone other than me as the Primary
Beneficiary. Furthermore, I hereby acknowledge that (1) the effect of my consent to this election will cause me to forfeit
benefits I would otherwise be entitled to receive upon my spouse’s death; (2) this beneficiary designation is not valid
unless I consent to it; and (3) my consent is irrevocable unless my spouse revokes the beneficiary designation.
Spouse’s Signature
Date
Witnessed by Notary Public
If Notary Public, Commission Expires
V.
Participant Signature
Participant Signature Required
Executed this
Date
day of
,
.
Witnessed by Notary Public:
Complete separate forms for participating owners and participating spouses.
Delaware Charter Guarantee & Trust Company d/b/a Principal Trust Company
TR301-1
Page 2 of 3
12/2007
Mailing Address:
P.O. Box 8963
Wilmington, DE 19899-8963
800-209-9010 Fax: 302-999-9554
[email protected]
Beneficiary Guidelines
Important Guidelines
•
•
•
•
•
•
•
Beneficiary designations are legal documents stating who is to receive the death benefits and how benefits are to
be paid. Without designations, benefits will be paid to the spouse as primary beneficiary or the participant’s estate
as the contingent beneficiary.
It is required that each participant complete the Beneficiary Designation form when he/she becomes eligible to
participate in the plan.
If you are married and designate a beneficiary other than your spouse, your spouse must consent in writing on the
Beneficiary Designation form. (Spouse signature MUST BE STAMPED BY NOTARY)
At any time, the beneficiary information can be changed to reflect a new designation by completing a Beneficiary
Designation form. The original copy of this form must be maintained in the employer’s files. A copy of this form
must be sent to us, so we can keep our records current. Mail, fax or email ([email protected]) a
copy to Principal Trust.
Principal Trust Company will not accept any altered forms. Each Beneficiary Designation form must be clear and
complete. We cannot accept requests with items crossed out. If we are unsure of the designation chosen, we will
ask for clarification on a new form.
Words like “or” “and/or” cannot not be used because it does not clearly explain how the assets should be
distributed. The Allocation Percentage section of the Beneficiary Designation form should be completed with the
percentage of assets you want allocated to each beneficiary. Allocation percentages do not have to be the same
percentage for all beneficiaries, but they must total 100% for all primary and contingent beneficiaries.
We strongly suggest that you consult with your attorney to determine the correct wording. Principal Trust Company
is not authorized to, and cannot provide legal advice.
Unacceptable Designations
•
•
Last Will and Testament
Animals named as beneficiaries
Sample Designations
Name
Relationship
Address
Allocation
One Beneficiary
John Smith
Father
##########
100%
Two Beneficiaries
John Smith
Mary Smith
Father
Mother
##########
##########
50%
50%
Primary and
Contingent
Mary Smith-Primary
John Smith-Contingent
Mother
Brother
##########
##########
100%
100%
Estate
My Estate
Trust
XXX Trust Company
Minor Children
Consult with your attorney for directions when naming minor children as beneficiaries
100%
Trustee in trust (under
trust name) dated
(date established)
Trustee’s address
100%
Delaware Charter Guarantee & Trust Company d/b/a Principal Trust Company
TR343-1
Page 1 of 1
12/2008