BENEFICIARY DESIGNATION FORM

ACCOUNT OWNER INFORMATION

Full Legal Name: [FULL LEGAL NAME]
Date of Birth: [DATE OF BIRTH]
Social Security Number: [SSN]
Current Address: [STREET ADDRESS], [CITY], [STATE] [ZIP CODE]
Phone Number: [PHONE NUMBER]
Email Address: [EMAIL ADDRESS]

ACCOUNT INFORMATION

Financial Institution: [FINANCIAL INSTITUTION NAME]
Account Type: [ACCOUNT TYPE (e.g., 401(k), IRA, Life Insurance Policy, Annuity, Bank Account)]
Account Number: [ACCOUNT NUMBER]
Policy Number (if applicable): [POLICY NUMBER]

PRIMARY BENEFICIARY DESIGNATION

I hereby designate the following individual(s) and/or entity(ies) as my primary beneficiary(ies) to receive the proceeds of the above-referenced account upon my death. If multiple beneficiaries are named, the percentages must total 100%.

Primary Beneficiary 1

Full Legal Name: [PRIMARY BENEFICIARY 1 NAME]
Relationship to Account Owner: [RELATIONSHIP]
Date of Birth: [DATE OF BIRTH]
Social Security Number/Tax ID: [SSN/TAX ID]
Current Address: [STREET ADDRESS], [CITY], [STATE] [ZIP CODE]
Phone Number: [PHONE NUMBER]
Email Address: [EMAIL ADDRESS]
Percentage of Benefits: [PERCENTAGE]%

Primary Beneficiary 2

Full Legal Name: [PRIMARY BENEFICIARY 2 NAME]
Relationship to Account Owner: [RELATIONSHIP]
Date of Birth: [DATE OF BIRTH]
Social Security Number/Tax ID: [SSN/TAX ID]
Current Address: [STREET ADDRESS], [CITY], [STATE] [ZIP CODE]
Phone Number: [PHONE NUMBER]
Email Address: [EMAIL ADDRESS]
Percentage of Benefits: [PERCENTAGE]%

Primary Beneficiary 3

Full Legal Name: [PRIMARY BENEFICIARY 3 NAME]
Relationship to Account Owner: [RELATIONSHIP]
Date of Birth: [DATE OF BIRTH]
Social Security Number/Tax ID: [SSN/TAX ID]
Current Address: [STREET ADDRESS], [CITY], [STATE] [ZIP CODE]
Phone Number: [PHONE NUMBER]
Email Address: [EMAIL ADDRESS]
Percentage of Benefits: [PERCENTAGE]%

CONTINGENT BENEFICIARY DESIGNATION

I hereby designate the following individual(s) and/or entity(ies) as my contingent beneficiary(ies) to receive the proceeds of the above-referenced account upon my death if all of my primary beneficiaries predecease me or disclaim their shares. If multiple contingent beneficiaries are named, the percentages must total 100%.

Contingent Beneficiary 1

Full Legal Name: [CONTINGENT BENEFICIARY 1 NAME]
Relationship to Account Owner: [RELATIONSHIP]
Date of Birth: [DATE OF BIRTH]
Social Security Number/Tax ID: [SSN/TAX ID]
Current Address: [STREET ADDRESS], [CITY], [STATE] [ZIP CODE]
Phone Number: [PHONE NUMBER]
Email Address: [EMAIL ADDRESS]
Percentage of Benefits: [PERCENTAGE]%

Contingent Beneficiary 2

Full Legal Name: [CONTINGENT BENEFICIARY 2 NAME]
Relationship to Account Owner: [RELATIONSHIP]
Date of Birth: [DATE OF BIRTH]
Social Security Number/Tax ID: [SSN/TAX ID]
Current Address: [STREET ADDRESS], [CITY], [STATE] [ZIP CODE]
Phone Number: [PHONE NUMBER]
Email Address: [EMAIL ADDRESS]
Percentage of Benefits: [PERCENTAGE]%

SPECIAL DESIGNATIONS

Distribution Method (select one)

• Per Stirpes: If a named beneficiary predeceases me, their share shall be distributed to their descendants.
• Per Capita: If a named beneficiary predeceases me, their share shall be distributed equally among the surviving named beneficiaries.

Trust as Beneficiary (if applicable)

Trust Name: [TRUST NAME]
Date of Establishment: [DATE OF ESTABLISHMENT]
Tax ID Number: [TRUST TAX ID]
Trustee Name: [TRUSTEE NAME]
Trustee Address: [TRUSTEE ADDRESS]
Trustee Phone Number: [TRUSTEE PHONE]
Trustee Email: [TRUSTEE EMAIL]

Charity as Beneficiary (if applicable)

Official Charity Name: [CHARITY NAME]
Tax ID Number (EIN): [CHARITY TAX ID]
501(c)(3) Status: [YES/NO]
Charity Address: [CHARITY ADDRESS]
Charity Phone Number: [CHARITY PHONE]
Charity Contact Person: [CHARITY CONTACT]

Minor Beneficiary Provisions (if applicable)

For any beneficiary who is a minor at the time of distribution, I direct that such beneficiary's share be distributed as follows (select one):

• To a custodian under the Uniform Transfers to Minors Act (UTMA) or Uniform Gifts to Minors Act (UGMA) of the state of [STATE], with [CUSTODIAN NAME] as custodian, until the minor reaches the age of [AGE].

• To the trustee of a trust established for the benefit of the minor under my last will and testament or under a separate trust agreement.

• To the legal guardian of the minor.

Special Needs Beneficiary Provisions (if applicable)

For [SPECIAL NEEDS BENEFICIARY NAME], I direct that their share be distributed to the [SPECIAL NEEDS TRUST NAME], dated [TRUST DATE], with [TRUSTEE NAME] as trustee, to be held and administered according to the terms of said trust for the benefit of [SPECIAL NEEDS BENEFICIARY NAME].

SPOUSAL CONSENT (if applicable)

I, [SPOUSE NAME], am the spouse of the Account Owner named above. I understand that I may have certain rights to the assets in this account under applicable state or federal law. I hereby consent to the beneficiary designation(s) made by my spouse. I understand that by signing this consent, I may be waiving rights to receive assets in this account upon my spouse's death. I further understand that my consent is irrevocable unless my spouse revokes or changes the beneficiary designation.

Spouse Signature: ________________________________ Date: ________________

Notary Acknowledgment:

State of ________________ County of ________________

On this _____ day of ____________, [YEAR], before me personally appeared [SPOUSE NAME], known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he/she executed the same for the purposes therein contained.

Notary Public Signature: ________________________________ My Commission Expires: ________________ [NOTARY SEAL]

TAX ACKNOWLEDGMENTS

I understand that my beneficiary designations may have significant tax implications for my beneficiaries. I acknowledge the following:

1. For retirement accounts, beneficiaries may be subject to Required Minimum Distribution rules and the SECURE Act's 10-year distribution rule for non-eligible designated beneficiaries.

2. Different tax consequences may apply to different types of accounts (e.g., Traditional vs. Roth IRAs).

3. Estate, inheritance, and income tax consequences may vary based on the type of beneficiary (individual, trust, charity) and their relationship to me.

4. I have been advised to consult with qualified tax and legal professionals regarding the tax implications of my beneficiary designations.

COORDINATION WITH ESTATE PLAN

I acknowledge that these beneficiary designations are separate from and may supersede provisions in my will or trust regarding the same assets. I have reviewed my overall estate plan to ensure these designations align with my broader estate planning goals and objectives.

CERTIFICATION AND SIGNATURE

I hereby revoke all prior beneficiary designations made with respect to the account identified above. I understand that I may change this designation at any time by submitting a new beneficiary designation form to the financial institution or account provider. I certify that the information provided on this form is complete and accurate to the best of my knowledge.

I understand that if I have designated a trust as beneficiary, it is my responsibility to ensure that the trust is properly structured to receive the specific type of asset, particularly for retirement accounts.

I acknowledge that certain state laws, including community property laws, may affect the validity of this beneficiary designation, and I have consulted with legal counsel as necessary to ensure compliance with applicable laws.

Account Owner Signature: ________________________________ Date: ________________

WITNESS ATTESTATION (if required)

The foregoing instrument was signed, published, and declared by the Account Owner as their Beneficiary Designation Form in our presence, and we, at the Account Owner's request and in their presence, and in the presence of each other, have subscribed our names as witnesses thereto, believing the Account Owner to be of sound mind and under no constraint or undue influence.

Witness 1 Signature: ________________________________ Date: ________________ Printed Name: ________________________________ Address: ________________________________

Witness 2 Signature: ________________________________ Date: ________________ Printed Name: ________________________________ Address: ________________________________

NOTARY ACKNOWLEDGMENT (if required)

State of ________________ County of ________________

On this _____ day of ____________, [YEAR], before me personally appeared [ACCOUNT OWNER NAME], known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he/she executed the same for the purposes therein contained.

Notary Public Signature: ________________________________ My Commission Expires: ________________ [NOTARY SEAL]

SUBMISSION INSTRUCTIONS

1. Complete all required fields on this form.

2. Sign and date the form in the presence of witnesses and/or a notary public if required.

3. Attach any required supporting documentation (e.g., trust certification, marriage certificate, divorce decree).

4. Submit the completed form to:

   [FINANCIAL INSTITUTION NAME] [ATTENTION: BENEFICIARY SERVICES] [MAILING ADDRESS] [CITY, STATE ZIP]

5. Retain a copy of this form and all supporting documentation for your records.

6. Contact [FINANCIAL INSTITUTION CONTACT INFORMATION] to confirm receipt and processing of this form.

PERIODIC REVIEW REMINDER

It is recommended that you review your beneficiary designations periodically, especially after major life events such as:

• Marriage or divorce
• Birth or adoption of a child
• Death of a beneficiary
• Significant changes in financial circumstances
• Changes in tax laws or regulations
• Relocation to a different state

FOR FINANCIAL INSTITUTION USE ONLY

Date Received: ________________ Processed By: ________________ Date Processed: ________________ Confirmation Sent: ________________ Special Instructions: ________________