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Designation of Payable on
Death (POD) Beneficiary Form
Please use this form or sign in to your Capital One Bank account online to designate or change the beneficiary(ies) for the
account(s) indicated below.
Before you begin, please know that…
The account holder authorizing the changes must be at least 18 years old
A maximum of 10 beneficiaries may be added to each of your accounts
Beneficiaries must be individuals and cannot be Trusts
This form will revoke all prior death beneficiary designations made by you for the account(s) listed below. Please be
sure to list all beneficiaries, including existing beneficiaries currently designated on your account(s).
If you want to designate different beneficiaries for different accounts, please fill out one form for each set of beneficiaries.
Check this box to remove all beneficiaries from the accounts listed below. (If checked, do not list any beneficiaries on page 2)
Accounts for POD Beneficiary Designations
Print this page again if you need to list more than 10 accounts
Account Holder’s Full Name
Full Account Number
Full Account Number
Full Account Number
Full Account Number
Full Account Number
Full Account Number
Full Account Number
Full Account Number
Full Account Number
Full Account Number
Products and services are offered by Capital One, N.A., Member FDIC. ©2020 Capital One. All Rights Reserved.
Page 1 of 3
Beneficiary Information
POD Beneficiary Information
All information for each Beneficiary must be completed in full
Full Name
Date of Birth
Tax ID (SSN or ITIN)
Beneficiary
Full Address (Street, City, State, ZIP) – US States & Territories Only
Full Name
Date of Birth
Tax ID (SSN or ITIN)
Beneficiary
Full Address (Street, City, State, ZIP) – US States & Territories Only
Full Name
Date of Birth
Tax ID (SSN or ITIN)
Beneficiary
Full Address (Street, City, State, ZIP) – US States & Territories Only
Full Name
Date of Birth
Tax ID (SSN or ITIN)
Beneficiary
Full Address (Street, City, State, ZIP) – US States & Territories Only
Full Name
Date of Birth
Tax ID (SSN or ITIN)
Beneficiary
Full Address (Street, City, State, ZIP) – US States & Territories Only
Products and services are offered by Capital One, N.A., Member FDIC. ©2020 Capital One. All Rights Reserved.
Page 2 of 3
Signature & Notarization
Please review the following and acknowledge by signing below:
Upon the death of all owners, the account(s) will only be paid to the Beneficiaries designated on this form. If multiple Beneficiaries are designated, funds
will be divided equally between all Beneficiaries.
If you are married and live in a community property state and your spouse is not named as your sole primary Beneficiary, you should consult your legal
advisor about how your state’s community property law may affect the validity of your Beneficiary(ies) designation.
You should consult your legal or tax advisor to determine whether a POD designation is appropriate for your specific situation. By accepting a Beneficiary
designation of record, Capital One will not assume and will have no responsibility or liability with respect to the legal or tax consequences of the
designation, including but not limited to the impact on the designation of community property or laws governing inheritance of property.
Account Holder’s Full Name
Date of Birth
Account Holder’s Signature
COMMONWEALTH / STATE OF ________________)
CITY / COUNTY OF ________________)
The foregoing instrument was SWORN TO AND SUBSCRIBED before me
on this, the _____ day of __________, 20___, by ________________, who
personally appeared and is [ ] personally known to me, or [ ] produced
the following identification ________________.
Signature of Notary Public
Notary Registration Number
Commission Expiration
Louisiana Customers Only
Witness Name (Printed)
Witness Name (Printed)
Witness Signature
Witness Signature
Date
Date
Products and services are offered by Capital One, N.A., Member FDIC. ©2020 Capital One. All Rights Reserved.
Page 3 of 3
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Fax or Mail This Form
Please review all the information included in this form for completion and accuracy before sending it to us. We will not
be able to accept it if required fields are illegible or incomplete.
Fax or mail this form using the number or address below. You may also bring this form to a Capital One branch location to
submit on your behalf.
For your safety, we’ve temporarily closed a limited number of branches in response to COVID-19, where there
wasn’t a form of physical separation—such as protective glass or drive-up servicing. Any Capital One locations that
are open can be found at locations.capitalone.com and are practicing guidelines set forth by the CDC. Although our
employees are working diligently to respond to your needs, you may experience processing delays. We appreciate your
patience and understanding.
If you have any questions, give us a call at 1-888-464-0727, 8 a.m.–11 p.m. ET, 7 days a week. We’ll be happy to help you.
Mail:
Capital One
PO Box 60
St. Cloud, MN 56302-0060
Fax:
888-464-3220
You do not need to include this page when faxing or mailing
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Completed 30 July 2020

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