ICMA-RC • Attn: Workow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400/for 403(b) plans 833-438-4032 • www.icmarc.org • Fax 202-682-6439
40082-1118-385
BENEFICIARY DESIGNATION FORM — PAGE 2 OF 2
Social Security Number
Employer Plan Number
_________________
_______ - ______ - _________
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 _____________
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 beneciary for at least 50% of the account, unless the spouse waives his/her right by consenting to an alternative beneciary
designation. By signing below, you (the participant’s spouse) are consenting to the benet percentage specied below and the participant’s beneciary
designation(s) on page 1 of this form.
401 Dened Contribution/403(b) Retirement Plans Many 401/403(b) plans require that a married participant designate his/her spouse as the
primary beneciary for 100% of the account, unless the spouse waives his/her right by consenting to an alternative beneciary designation. By signing
below, you are consenting to the benet percentage specied below and the participant’s beneciary 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 beneciary designations.
ICMA-RC is not responsible for a participant’s failure to properly designate a beneciary in accordance with state law. Failure to satisfy state law
requirements may result in a beneciary designation being invalidated, and benets being paid in accordance with state law.
Spousal Consent and Acknowledgement By signing below, I agree to waive my beneciary rights in my spouse’s retirement plan account, and consent
to 1) receive the benet percentage specied below, and 2) the beneciary designation on page 1 of this form. I understand this waiver will result in some
or all of my spouse’s death benet being paid to someone other than me. I further understand that future changes to my spouse’s beneciary designations
will not be valid unless I consent to any such changes.
Spouse Benet Percentage (whole % only): ___ ___ ___ % (This percentage should match the percentage, if any, specied on page 1 of the form. Write “0” if applicable.)
_________________________________________________________
____ ___/____ ____ /____ ____ ____ ____
Spouse Signature Month Day Year
_________________________________________________________
Name (Please Print)
4. SPOUSAL CONSENT
5. WITNESS
• For 457(b) 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 dened contribution plans, the above spousal consent must be witnessed by either an authorized employer plan representative or a Notary
Public.
• For 403(b) retirement plans, the above spousal consent must be witnessed by either an authorized employer plan representative or a Notary Public.
Last First M.I.
Full Name of Participant (Please Print)
__________________________________________________________________________
PLEASE REMEMBER TO MAKE A COPY FOR YOUR RECORDS.
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