457 Beneficiary Change Form
I. Participant Information
Participant Name: SSN:
Telephone Number: Birth Date:
Address:
City: State: Zip:
II. Account Information
457 Plan Employer:
Investment Company: Account Number:
III. Beneficiary Designations
[ ] Primary [ ] Contingent Percent:
Name: SSN:
Relation: Birth Date:
[ ] Primary [ ] Contingent Percent:
Name: SSN:
Relation: Birth Date:
[ ] Primary [ ] Contingent Percent:
Name: SSN:
Relation: Birth Date:
[ ] Primary [ ] Contingent Percent:
This form is used to change the
beneficiary designations on a 457 plan
account administered by Harold Dance
Investments. Additional paperwork
may be required for certain types of
457 accounts.
For questions regarding this form, to
request a different form, or to discuss
other aspects of the 457 plan, please
contact Harold Dance Investments.
Phone:
435-752-8484
Toll Free:
800-327-5400
Name: SSN:
Relation: Birth Date:
[ ] Primary [ ] Contingent Percent:
Name: SSN:
Relation: Birth Date:
[ ] Primary [ ] Contingent Percent:
Name: SSN:
Relation: Birth Date:
IV. Comments
V. Signature
EMPLOYEE Signature: Date:
This form is used to change the
beneficiary designations on a 457 plan
account administered by Harold Dance
Investments. Additional paperwork
may be required for certain types of
457 accounts.
For questions regarding this form, to
request a different form, or to discuss
other aspects of the 457 plan, please
contact Harold Dance Investments.
Phone:
435-752-8484
Toll Free:
800-327-5400
Please return the completed form via
mail or fax.
Mail:
Harold Dance Investments
360 N. Main St.
Logan UT 84321
Fax:
435-752-8487
360 North Main Street • Logan, Utah 84321
Telephone: 435-752-8484 • Toll-free: 800-327-5400 • Fax: 435-752-8487
