Fillable BENEFICIARY DESIGNATION FORM (City of Riverside, California)

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BENEFICIARY DESIGNATION FORM (City of Riverside, California)

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  • 30 check-boxes
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BROWSE CITY OF RIVERSIDE, CALIFORNIA (CA) FORMS

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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
COMPLETING THE FORM
SECTION 1 – YOUR PERSONAL INFORMATION
£ Enter your Employer Plan Number and Employer Plan Name, which you can quickly obtain from your quarterly statement or by
logging in to your account online at www.icmarc.org/login.
£ You must enter your full Social Security Number and Name.
£ Enter also your Marital Status to help ensure Spousal Consent requirements are met.
SECTION 2 – YOUR BENEFICIARY DESIGNATIONS
£ For each beneciary, check either “Primary” or “Contingent.”
£ Enter at least one primary beneciary. For each beneciary, check one “Relationship.”
£ You may also enter contingent beneciaries.
£ e percentages for your primary and/or contingent beneciaries must each equal 100%.
£ Each individual percent must be a whole number, such as “33%” or “34%” and not a fraction, such as “33⅓% or “33.33%.”
SECTION 3 – YOUR SIGNATURE
£ Sign and date.
SECTION 4 and 5 – SPOUSAL CONSENT and WITNESS (when required)
£ If you are married and do not designate your spouse as primary beneciary, your spouse may be required to sign and date section 4 in
front of a Notary Public or an employer plan representative (who would complete section 5) if:
£ 457(b) plans: You live in a Community Property State (see section 4 for more information)
£ 401 plans: Plan rules require it (call ICMA-RC at 800-669-7400 to conrm)
£ 403(b) plans: Plan rules require it (call ICMA-RC at 833-438-4032 to conrm)
SENDING THE FORM
£ Include the completed form.
£ Fax or mail the completed Form to ICMA-RC. If you fax the form to ICMA-RC, there is no need to send it to us by mail.
Fax: ICMA-RC
Attn: Workow Management Team
202-682-6439
Mail: ICMA-RC
Attn: Workow Management Team
P.O. Box 962770
Washington, DC 20090-6220
BENEFICIARY DESIGNATION FORM
Use this Checklist to help you complete the form on the following pages so that we can update the beneciaries for
your 457(b), 401, and/or 403(b) plan accounts when Spousal Consent is required.
As a reminder, if Spousal Consent is not required, update your beneciary information online by logging in to
your account at www.icmarc.org/login.
By providing all the necessary information, we can avoid delays and take care of your request
as soon as possible.
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 INSTRUCTIONS
Please note: You only need to complete this form if your beneciary designation requires spousal consent. See Sec-
tion 4 to see if this applies to you.
In the event of your death, your designated beneciary(ies) will be entitled to any assets remaining in your account.
Please provide all of the requested information for each beneciary  this information will help ICMA-RC locate your
beneciaries if necessary. You can always update your beneciary information online by following the instructions
below.
Designating beneciaries 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 beneciaries are no longer
living at the time of your death, benets will be paid to your contingent beneciaries.
• Your beneciaries may receive more tax advantages.
Percent of Benet 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 beneciary designations, the benet
will be allocated equally among all beneciaries.
Trust Beneciaries – If you name a trust as your primary or contingent beneciary, you must submit a complete copy of
your entire trust document with this form.
Update Beneciary Information Online
• Log in to ICMA-RC’s Account Access at www.icmarc.org.login.
• Go to the Manage My Account tab and click the My Prole link.
• Click the Beneciaries link.
• Click the Update Beneciaries button and enter your beneciary information.
Married Participants
If you do not designate your spouse as the primary beneciary for your account, your spouse may be required to consent
to your beneciary 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 benets from
the Fund, your spouse must be designated as the primary beneciary for 100% of your account, both at the time
you Lock-In the benet 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, there is no need to send it to us by mail. Completion of page 2 is only required if your
beneciary designation requires spousal consent.
Fax: Mail:
ICMA-RC ICMA-RC
ATTN: Workow Management Team ATTN: Workow Management Team
202-682-6439 P.O. Box 96220
Washington, DC 20090-6220
Please keep a copy of completed form for your records.
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 1 OF 2
• Update your beneciary designations and/or designate additional beneciaries at any time via Account Access at www.icmarc.org/login.
• Your “Primary” beneciary(ies) must total 100% and your “Contingent” beneciary(ies) if applicable must also total 100%.
• Use whole percentages only (e.g., 50%, not 33.33% or 33
1
/3 %).
• Check one “Beneciary Type” and one “Relationship” for each beneciary. Failure to do so may result in your designation being invalid.
Beneciary Type: p Primary Relationship (Check One): Spouse Non-Spouse Trust* Charity
________________________________________________________ ____ /____ /_______ ______ - ______ - _______ _______%
Name Date of Birth Social Security Number % of Benet
Beneciary Type (Check One): Primary Contingent Relationship (Check One): Spouse Non-Spouse Trust* Charity
________________________________________________________ ____ /____ /________ ______ - ______ - _______ _______%
Name Date of Birth Social Security Number % of Benet
Beneciary Type (Check One): Primary Contingent Relationship (Check One): Spouse Non-Spouse Trust* Charity
________________________________________________________ ____ /____ /_______ ______ - ______ - _______ _______%
Name Date of Birth Social Security Number % of Benet
Beneciary Type (Check One): Primary Contingent Relationship (Check One): Spouse Non-Spouse Trust* Charity
________________________________________________________ ____ /____ /_______ ______ - ______ - _______ _______%
Name Date of Birth Social Security Number % of Benet
Beneciary Type (Check One): Primary Contingent Relationship (Check One): Spouse Non-Spouse Trust* Charity
________________________________________________________ ____ /____ /_______ ______ - ______ - _______ _______%
Name Date of Birth Social Security Number % of Benet
* Trust Beneciaries – You must submit a copy of your entire trust document with the enrollment form if you desire the beneciaries of the trust to be treated as designated beneciaries for the purpose of determining required
minimum distributions.
Designate additional beneciaries 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 beneciary information.
1) Use this form to designate beneciaries for your employer-sponsored retirement plan with ICMA-RC.
2) You only need to complete this form if your beneciary designation requires spousal consent. Otherwise, you may update your beneciary
information quickly and securely via Account Access at www.icmarc.org/login.
- Spousal Consent – If you are married and do not designate your spouse as primary beneciary 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.
Social Security Number (for tax-reporting purposes)
________ - ______ - ___________
Last First M.I.
Full Name of Participant
________________________________________________________________________________
1. PERSONAL INFORMATION
2. BENEFICIARY DESIGNATION
Employer Plan Number Employer Plan Name
_________________ ___________________________________________________________________
Date of Birth
_______ / ______ /___________
Month Day Year
Email Address
____________________________________
(whole % only)
(whole % only)
(whole % only)
(whole % only)
(whole % only)
________________________________________________________________ _______ / ______ /____________
Participant Signature Month Day Year
3. SIGNATURES
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(continued on back)
Marital Status — Check one box Married Single
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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
THIS PAGE INTENTIONALLY LEFT BLANK
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 beneciary for at least 50% of the account, unless the spouse waives his/her right by consenting to an alternative beneciary
designation. By signing below, you (the participant’s spouse) are consenting to the benet percentage specied below and the participant’s beneciary
designation(s) on page 1 of this form.
401 Dened Contribution/403(b) Retirement Plans  Many 401/403(b) plans require that a married participant designate his/her spouse as the
primary beneciary for 100% of the account, unless the spouse waives his/her right by consenting to an alternative beneciary designation. By signing
below, you are consenting to the benet percentage specied below and the participant’s beneciary 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 beneciary designations.
ICMA-RC is not responsible for a participant’s failure to properly designate a beneciary in accordance with state law. Failure to satisfy state law
requirements may result in a beneciary designation being invalidated, and benets being paid in accordance with state law.
Spousal Consent and Acknowledgement  By signing below, I agree to waive my beneciary rights in my spouse’s retirement plan account, and consent
to 1) receive the benet percentage specied below, and 2) the beneciary designation on page 1 of this form. I understand this waiver will result in some
or all of my spouse’s death benet being paid to someone other than me. I further understand that future changes to my spouse’s beneciary designations
will not be valid unless I consent to any such changes.
Spouse Benet Percentage (whole % only): ___ ___ ___ % (This percentage should match the percentage, if any, specied 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 dened 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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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
THIS PAGE INTENTIONALLY LEFT BLANK
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
THIS PAGE INTENTIONALLY LEFT BLANK
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
THIS PAGE INTENTIONALLY LEFT BLANK
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BENEFICIARY DESIGNATION FORM (City of Riverside, California)

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Completed 4 August 2020

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