Fillable SP Beneficiary Designation Form (MidAmerica)

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SP Beneficiary Designation Form (MidAmerica)

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The SP Beneficiary Designation Form (MidAmerica) form is 1 page long and contains:

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SP BENEFICIARY FORM 2015.1117
Section A: General Information:
Employer (District) Name:
Employee Name (Last, First, M.I.):
Social Security #:
Address:
City:
State:
Zip:
Home Telephone:
Work Telephone:
E-Mail Address:
Date of Birth:
Date of Hire:
Section B: Beneficiary Designation (you must check either married or unmarried)
Unmarried Participant
I understand that I must elect my spouse as sole Primary Beneficiary under this Plan
unless he/she consents in writing to my naming another Primary Beneficiary. (Please
complete Section C if naming a Primary Beneficiary other than your spouse.)
I understand that the following designation becomes null and void in the event of my
marriage. I will promptly inform MidAmerica Administrative & Retirement Solutions of any
change in my marital status.
Primary Beneficiary
(If additional space is required, please attach a separate page.)
Name (Last Name, First Name, M.I.)
Social Security Number
Date of Birth (Mo/Day/Yr)
Relationship to Participant
% Share
Address
City
State
Zip Code
Contingent Beneficiary
Name (Last Name, First Name, M.I.)
Social Security Number
Date of Birth (Mo/Day/Yr)
Relationship to Participant
% Share
Address
City
State
Zip Code
Name (Last Name, First Name, M.I.)
Social Security Number
Date of Birth (Mo/Day/Yr)
Relationship to Participant
% Share
Address
City
State
Zip Code
Section C: Spousal Consent
For the spouse’s consent to be effective, the spouse must sign below in the presence of a notary public.
I consent to my spouse’s election to designate me as the beneficiary of less than 50% of my spouse’s account balance in the Plan in the event of my spouse’s death while
participating in the Plan. I understand that the effect of my consent is to waive the requirement that 50% of my spouse’s account balance in the Plan be paid to me in the event of
my spouse’s death while my spouse is a participant in the Plan. I further understand that my spouse’s election is not effective unless I consent to it and that this consent given by me
is irrevocable unless the election made by my spouse is changed.
Participant's Spouse's Signature
Date
NOTARY PUBLIC - STATE OF _________________________________________ COUNTY OF __________________________________________
I, ________________________, a Notary Public for said County and State do hereby certify that ___________________________________ personally appeared before me this
day and acknowledged the due execution of the foregoing instrument.
(Official Seal)
NOTARY PUBLIC My commission expires:____________________________________
Section D: Internet Access for Plan Participants
MidAmerica Administrative & Retirement Solutions provides Internet access for employee inquiries and questions regarding company retirement plan accounts. Our website address
is www.midamerica.biz. Live operator assistance is available Monday through Thursday from 8:30 AM to 8:00 PM and Friday 8:30 AM to 6:00 PM Eastern Time at our toll-free
number (800) 430-7999.
Section E: Participant Certification and Signature
By signing below, I agree that the funds involved and associated financial risks have been described to me such that the allocation selection is based on my best prudent
understanding in the interest of my retirement funding goals. I also understand that if I outlive my Primary Beneficiary, benefits will be paid to my estate on my death unless I
designate a Contingent Beneficiary(ies).
Employee Signature
Date
Please return this completed form to: MidAmerica Administrative & Retirement Solutions
Attn: DEPT SPADMIN
402 South Kentucky Avenue, Suite 500, Lakeland, FL 33801
Fax: (863) 686-9727
Special Pay Plan
Beneficiary Designation Form
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SP Beneficiary Designation Form (MidAmerica)

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Completed 28 July 2021

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