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301 / 2303 (Rev. 4/2015) ©2015 Ascensus, Inc.
Name _______________________________________________________
Address ____________________________________________________
City/State/ZIP ________________________________________________
Date of Birth _________________ Relaonship ____________________
Tax ID (SSN/TIN) ____________________ Percent Designated _________
Name _______________________________________________________
Address ____________________________________________________
City/State/ZIP ________________________________________________
Date of Birth _________________ Relaonship ____________________
Tax ID (SSN/TIN) ____________________ Percent Designated _________
Name _______________________________________________________
Address ____________________________________________________
City/State/ZIP ________________________________________________
Date of Birth _________________ Relaonship ____________________
Tax ID (SSN/TIN) ____________________ Percent Designated _________
Name _______________________________________________________
Address ____________________________________________________
City/State/ZIP ________________________________________________
Date of Birth _________________ Relaonship ____________________
Tax ID (SSN/TIN) ____________________ Percent Designated _________
Name _______________________________________________________
Address ____________________________________________________
City/State/ZIP ________________________________________________
Date of Birth _________________ Relaonship ____________________
Tax ID (SSN/TIN) ____________________ Percent Designated _________
Name _______________________________________________________
Address ____________________________________________________
City/State/ZIP ________________________________________________
Date of Birth _________________ Relaonship ____________________
Tax ID (SSN/TIN) ____________________ Percent Designated _________
Name _______________________________________________________
Address ____________________________________________________
City/State/ZIP ________________________________________________
Date of Birth _________________ Relaonship ____________________
Tax ID (SSN/TIN) ____________________ Percent Designated _________
Name _______________________________________________________
Address ____________________________________________________
City/State/ZIP ________________________________________________
Date of Birth _________________ Relaonship ____________________
Tax ID (SSN/TIN) ____________________ Percent Designated _________
Name _______________________________________________________
Address ____________________________________________________
City/State/ZIP ________________________________________________
Date of Birth _________________ Relaonship ____________________
Tax ID (SSN/TIN) ____________________ Percent Designated _________
Name _______________________________________________________
Address ____________________________________________________
City/State/ZIP ________________________________________________
Date of Birth _________________ Relaonship ____________________
Tax ID (SSN/TIN) ____________________ Percent Designated _________
CONTINGENT BENEFICIARIES (The total percentage designated must equal 100%. If more than one beneciary is designated and no percentages
are indicated, the beneciaries will be deemed to own equal share percentages in the IRA. The balance in the account will be payable to these
beneciaries if all primary beneciaries have predeceased the IRA owner.)
PART 4. SPOUSAL CONSENT
Spousal consent should be considered if either the trust or the residence of
the IRA owner is located in a community or marital property state.
CURRENT MARITAL STATUS
I Am Not Married – I understand that if I become married in the
future, I should review the requirements for spousal consent.
I Am Married – I understand that if I choose to designate a primary
beneciary other than or in addion to my spouse, my spouse should
sign below.
CONSENT OF SPOUSE
I am the spouse of the above-named IRA owner. I acknowledge that I have
received a fair and reasonable disclosure of my spouse’s property and
nancial obligaons. Because of the important tax consequences of giving
up my interest in this IRA, I have been advised to see a tax professional.
I hereby relinquish any interest that I may have in this IRA and consent to
the beneciary designaon indicated above. I assume full responsibility for
any adverse consequences that may result.
X____________________________________________ ____________________
Signature of Spouse Date (mm/dd/yyyy)
X____________________________________________ ____________________
Signature of Witness Date (mm/dd/yyyy)
PART 5. SIGNATURES
I understand that I may replace my beneciary designaons at any me by
compleng and delivering the proper form to the trustee or custodian.
The trustee or custodian has provided no tax or legal advice to me
regarding my beneciary designaons.
I designate the persons or enes named above as my primary and/or
conngent beneciaries of this IRA. I hereby revoke all prior beneciary
designaons, if any, made by me.
X____________________________________________ ____________________
Signature of IRA Owner Date (mm/dd/yyyy)
X____________________________________________ ____________________
Signature of Witness Date (mm/dd/yyyy)
Check here if addional beneciaries are listed on an aached addendum. Total number of addendums aached to this IRA _______________
Name of IRA Owner ______________________________________________________________, Account Number ______________________________