Fillable Form 1: 403 b Beneciary Designation General information (Capital Group)

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Form 1: 403 b Beneciary Designation General information (Capital Group)

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1 of 3
403
(
b
)
Beneciary Designation
04/21
Important: The beneciaries named on this form will replace any existing beneciary information listed on your account. You must
specify ALL Primary and Contingent Beneciaries on this form even if you are changing only one beneciary.
1
General information
Please type or print clearly.
First name of participant MI Last
Address City State ZIP
( )
Email address* Daytime phone
□
Check here if the mailing address listed above is new. Our records will be updated accordingly.
Marital status:
□
I am married.
(
See Section 3.
)
□
I am not married.
The beneciary designation below only applies to the following account(s):
( )
Ext.
Name of organization Daytime phone
*Your privacy is important to us. For information on our privacy policies, visit www.capitalgroup.com.
2
Beneciarydesignation
We encourage you to consult a professional regarding the tax-law and estate planning implications of your beneciary designation. All stated
percentages must be whole percentages
(
e.g., 33%, not 33.3%
)
. If the percentages do not add up to 100%, each beneciary’s share will be based
proportionately on the stated percentages. When a percentage is not indicated, the beneciaries’ shares will be divided equally.
Notes: • Your spouse may need to sign in Section 3. If you wish to name more than one trust or entity, customize your designation or need
more space, attach a separate page. Include the name, address, relationship, date of birth or trust, SSN/TIN and percentage for
each beneciary.
• If you name a trust as beneciary, provide the full legal name of the trust. Example: “The Davis Family Trust.”
A. Primary Beneciary
(
ies
)
: If any designated Primary Beneciary
(
ies
)
dies before I do, that beneciary’s share will be divided proportionately
among the surviving Primary Beneciaries unless otherwise indicated. If no Primary Beneciaries survive me, assets will be paid to the
named Contingent Beneciaries, if any.
1.
First name (print) MI Last name Sufx
OR
Name of trust or other entity (print)
Address City State ZIP
□ □ □ □ □ %
Spouse Child of owner Other person Trust Other entity Date of birth or trust
(
mm/dd/yyyy
)
SSN/TIN Whole % only
Continued on next page
Clear and reset form
2 of 3
403
(
b
)
Beneciary Designation
04/21
2
Beneciarydesignation
(
continued
)
2.
First name (print) MI Last name Sufx
Address City State ZIP
□ □ □ %
Spouse Child of owner Other person Date of birth
(
mm/dd/yyyy
)
SSN Whole % only
3.
First name (print) MI Last name Sufx
Address City State ZIP
□ □ □ %
Spouse Child of owner Other person Date of birth
(
mm/dd/yyyy
)
SSN Whole % only
Important: Section 2-A must be completed prior to completing Section 2-B.
B. Contingent Beneciary
(
ies
)
: If no Primary Beneciary survives me, pay my benets to the following Contingent Beneciary
(
ies
)
.
If any designated Contingent Beneciary
(
ies
)
dies before I do, that beneciary’s share will be divided proportionately among the surviving
Contingent Beneciaries unless otherwise indicated. If no Contingent Beneciaries survive me, assets will be paid according to the
Custodial Agreement default designation.
1.
First name (print) MI Last name Sufx
OR
Name of trust or other entity (print)
Address City State ZIP
□ □ □ □ □ %
Spouse Child of owner Other person Trust Other entity Date of birth or trust
(
mm/dd/yyyy
)
SSN/TIN Whole % only
2.
First name (print) MI Last name Sufx
Address City State ZIP
□ □ □ %
Spouse Child of owner Other person Date of birth
(
mm/dd/yyyy
)
SSN Whole % only
3.
First name (print) MI Last name Sufx
Address City State ZIP
□ □ □ %
Spouse Child of owner Other person Date of birth
(
mm/dd/yyyy
)
SSN Whole % only
3 of 3
403
(
b
)
Beneciary Designation
3
Spousalconsent
Please consult your nancial professional and/or employer about the need for spousal consent.
I am the spouse of the participant named in Section 1. I irrevocably consent to the designation made by my spouse to have any death benets
paid to the named beneciary(ies) specied in Section 2. I understand that the effect of such designation is to cause my spouse’s death
benet to be paid to a beneciary other than me, that such beneciary designation is not valid unless I consent to it and that my consent is
irrevocable unless my spouse revokes the beneciary designation.
X
/ /
Name of spouse of participant (print) Signature of spouse of participant Date (mm/dd/yyyy)
Note: If the employer sponsors an ERISA plan, the spousal consent must be witnessed or notarized. Please check with the Plan Sponsor
if you need more information regarding the ERISA status of the plan.
Witnessed by:
□
Plan representative
□
Notary public
X
/ /
Signature of witness Date (mm/dd/yyyy)
NOTARY: Afx seal here.
4
Signature
By signing below, I acknowledge that I have completed this beneciary designation form.
X
/ /
Signature of participant Date (mm/dd/yyyy)
If witnessed by a notary public, original signatures are required and this form
must be mailed. Otherwise, you may fax this form to (888) 421-4371.
This document may not be signed using Adobe Acrobat Reader’s "ll and sign" feature.
This document may not be signed using Adobe Acrobat Reader’s "ll and sign" feature.
Virginia Service Center
American Funds Service Company
P.O. Box 2560
Norfolk, VA 23501-2560
Overnight mail address
5300 Robin Hood Rd.
Norfolk, VA 23513-2430
Fax (888)-421-4371
Please mail or
fax this form to
the appropriate
service center.
(If you live outside
the U.S., mail the
form to the Indiana
Service Center.)
If you have questions or require more information, contact your nancial professional or call American Funds Service Company at
(
800
)
421-4225.
Indiana Service Center
American Funds Service Company
P.O. Box 6164
Indianapolis, IN 46206-6164
Overnight mail address
12711 N. Meridian St.
Carmel, IN 46032-9181
Fax (888)-421-4371
Lit. No. IR4BFM-009-0421O CGD/9075-S80722 © 2021 Capital Group. All rights reserved.
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Form 1: 403 b Beneciary Designation General information (Capital Group)

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Completed 18 August 2021

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