Fillable Change of Beneficiary Form

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Change of Beneficiary Form

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The Change of Beneficiary Form form is 4 pages long and contains:

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  • 36 check-boxes
  • 50 other fields

Country of origin: OTHERS
File type: PDF

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CONTINUED ON NEXT PAGE PAGE 1 of 4
Use this form to update beneficiaries only for the following retirement account
types: IRA, Roth IRA, SEP IRA or SAR SEP IRA.
All surviving beneficiaries will receive equal shares upon the death of account
owner unless otherwise indicated. Beneficiary allocations must equal 100%.
Please print or type in black ink.
Make sure you sign and date in Step 5 (page 4).
Step 1 - List the name that is on your account
____
______________________________________________________________________________________
Owner’s First Name Middle Initial Last Name
__________________________________________________________________________________________
Social Security Number Date of Birth Phone Number
Step 2 - List the accounts would you like to update
Select One:
All applicable retirement accounts under owner’s social security number (any Qualified Plans will need to be
updated separately)
Onl
y update these accounts:
__________________________________________________________________________________________
Specific accounts to be updated
Questions?
Call us at 800-525-3713
In a Hurry?
Update online at
janushenderson.com
- or -
Fax form to 877-319-3852
- - -
Change of Beneficiary Form
PO Box 219109 • Kansas City, MO 64121-9109 • 800-525-3713
Remember to sign on the last page
Change of Beneficiary Form
CONTINUED ON NEXT PAGE PAGE 2 of 4
Step 3 - Name your Primary beneficiaries
If
applicable, any beneficiary who passes away before the account owner will have their share divided proportion-
ally among the surviving beneficiaries. If you have more than four primary beneficiaries please attach a separate
sheet. The sum of all primary beneficiary designations must equal 100%.
P
rimary ______________________________________________________________________
Beneficiary #1 Name % of Account
Spouse
Non-Spouse ______________________________________________________________________
Trust Date of Birth or UA Date of Trust Social Security or Taxpayer ID Number
Other Entity
Minor* ______________________________________________________________________
*Custodian’s full name if beneficiary is a minor. Appoint one person as a custodian.You
cannot name yourself as custodian.
P
rimary ______________________________________________________________________
Beneficiary #2 Name % of Account
Non-Spouse
Trust ______________________________________________________________________
Other Entity Date of Birth or UA Date of Trust Social Security or Taxpayer ID Number
Minor*
__
____________________________________________________________________
*Custodian’s full name if beneficiary is a minor. Appoint one person as a custodian. You
cannot name yourself as custodian.
P
rimary ______________________________________________________________________
Beneficiary #3 Name % of Account
Non-Spouse
Trust ______________________________________________________________________
Other Entity Date of Birth or UA Date of Trust Social Security or Taxpayer ID Number
Minor*
__
____________________________________________________________________
*Custodian’s full name if beneficiary is a minor. Appoint one person as a custodian. You
cannot name yourself as custodian.
P
rimary ______________________________________________________________________
Beneficiary #4 Name % of Account
Non-Spouse
Trust ______________________________________________________________________
Other Entity Date of Birth or UA Date of Trust Social Security or Taxpayer ID Number
Minor*
__
____________________________________________________________________
*Custodian’s full name if beneficiary is a minor. Appoint one person as a custodian. You
cannot name yourself as custodian.
Total (must equal 100%):_______
Remember to sign on the last page
0.00
Change of Beneficiary Form
CONTINUED ON NEXT PAGE PAGE 3 of 4
Step 4 - (Optional) Name your Secondary (Contingent) beneficiaries
Secondary beneficiaries receive assets ONLY if no primary beneficiary survives you. Do NOT list any primary
beneficiaries here. If you have more than four secondary beneficiaries please attach a separate sheet. The sum
of all secondary beneficiary designations must equal 100%.
Secondary ______________________________________________________________________
Beneficiary #1 Name % of Account
Spouse
Non-Spouse ______________________________________________________________________
Trust Date of Birth or UA Date of Trust Social Security or Taxpayer ID Number
Other Entity
Minor* ______________________________________________________________________
*Custodian’s full name if beneficiary is a minor. Appoint one person as a custodian. You
cannot name yourself as custodian.
Secondary ______________________________________________________________________
Beneficiary #2 Name % of Account
Non-Spouse
Trust ______________________________________________________________________
Other Entity Date of Birth or UA Date of Trust Social Security or Taxpayer ID Number
Minor*
______________________________________________________________________
*Custodian’s full name if beneficiary is a minor. Appoint one person as a custodian. You
cannot name yourself as custodian.
Secondary ______________________________________________________________________
Beneficiary #3 Name % of Account
Non-Spouse
Trust ______________________________________________________________________
Other Entity Date of Birth or UA Date of Trust Social Security or Taxpayer ID Number
Minor*
______________________________________________________________________
*Custodian’s full name if beneficiary is a minor. Appoint one person as a custodian. You
cannot name yourself as custodian.
Secondary ______________________________________________________________________
Beneficiary #4 Name % of Account
Non-Spouse
Trust ______________________________________________________________________
Other Entity Date of Birth or UA Date of Trust Social Security or Taxpayer ID Number
Minor*
______________________________________________________________________
*Custodian’s full name if beneficiary is a minor. Appoint one person as a custodian. You
cannot name yourself as custodian.
Total (must equal 100%):_______
Remember to sign on the last page
0.00
PAGE 4 of 4
296-11-00756 03-21
Step 5 - Review and Sign
Pl
ease review the form to make sure all information is complete and accurate and all totals equal 100%.
Following the death of an account owner, Janus Services LLC does not have a duty to locate beneficiaries,
determine marital status or take a position if the beneficiary designation is disputed. In such instances, Janus
Henderson may delay the disbursement of assets until such a time that the parties resolve the dispute and
sufficient documentation of beneficiary status has been provided. We recommend that you periodically review
your beneficiary designations and promptly notify Janus Henderson of any necessary changes.
I certify that (if I am married and reside in a community property or marital property state) my spouse has
knowledge of and consents to the designation of a non-spouse beneficiary for this account. (Please consult
with a legal advisor regarding your beneficiary designation. Neither the custodian nor the plan sponsor will be
liable for any consequences resulting from failure to accurately represent spousal consent).
This will become part of the terms, conditions and representations of the shareholder’s application.
X____
_______________________________________________________________________
Signature of Owner Date
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Change of Beneficiary Form

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Completed 3 March 2022

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