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Page 1 of 3
301-SU CalSavers (Rev. 6/2019) ©2019 Ascensus, LLC
1. IRA OWNER INFORMATION (All fields required)
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—
Account Number Social Security Number or Taxpayer Identification Number
IRA Owner Legal Name (First) (M.I.)
IRA Owner Legal Name (Last)
—
—
Telephone Number (In case we have a question about your Account)
FORM TYPE AND DATE (Select and attach to the applicable form)
Original IRA Application Beneficiary Designation
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Applicable Form Dated (mm/dd/yyyy)
BENEFICIARY DESIGNATION ADDENDUM
A beneficiary is a designated individual or entity that will inherit the assets in your CalSavers account. A contingent beneficiary is a designated
individual or entity that will inherit the assets in your CalSavers account in the event all the primary beneficiaries have predeceased you. This
form can only be used to name additional beneficiaries that will not fit on the Beneficiary Designation form or IRA application. Complete
additional addendums as necessary.
Completed forms should be mailed to: CalSavers Overnight Address: CalSavers
PO Box 55759 95 Wells Avenue, Suite 155
Boston, MA 02205-5759 Newton, MA 02459
855-650-6918
saver.calsavers.com
8:00 am to 8:00 pm Pacific Standard Time M-F
Page 2 of 3
301-SU CalSavers (Rev. 6/2019) ©2019 Ascensus, LLC
2. BENEFICIARY DESIGNATION (All fields required)
I hereby designate the beneficiaries below, in addition to the beneficiaries designated on the attached form, as beneficiaries of this IRA.
PRIMARY BENEFICIARIES The total percentage designated for all primary beneficiaries of this IRA must equal 100%. Use whole numbers
when indicating the percentage for the beneficiary(ies). If more than one beneficiary is designated and no percentages are provided, the
beneficiaries will be deemed to own equal share percentages in the IRA.
First Name/Trust Name/Entity (M.I.)
Last Name/Trust Name/Entity
—
—
—
—
Social Security Number or Taxpayer Identification Number Birth Date or Date of Trust (mm/dd/yyyy)
Address (We cannot accept a PO Box)
—
City State Zip Code
Relationship
My Spouse
My Child
My Relative
Other Percent Designated
%
First Name/Trust Name/Entity (M.I.)
Last Name/Trust Name/Entity
—
—
—
—
Social Security Number or Taxpayer Identification Number Birth Date or Date of Trust (mm/dd/yyyy)
Address (We cannot accept a PO Box)
—
City State Zip Code
Relationship
My Spouse
My Child
My Relative
Other Percent Designated
%
Total Percentage of All Primary Beneficiaries
1
0
0
%
Page 3 of 3
301-SU CalSavers (Rev. 6/2019) ©2019 Ascensus, LLC
3. IRA OWNER SIGNATURE
I understand that I may replace my beneficiary designations at any time by completing and delivering the proper form to CalSavers. Neither the
IRA custodian nor CalSavers has provided tax or legal advice to me regarding my beneficiary designations. In addition, any applicable spousal
consent is provided on the attached form.
—
—
Signature of IRA Owner Date (mm/dd/yyyy)
CONTINGENT BENEFICIARIES The total percentage designated for all contingent beneficiaries of this IRA must equal 100%. Use whole
numbers when indicating the percentage for the beneficiary(ies). If more than one beneficiary is designated and no percentages are
provided, the beneficiaries will be deemed to own equal share percentages in the IRA. The balance in the account will be payable to these
beneficiaries if all primary beneficiaries have predeceased the IRA owner.
First Name/Trust Name/Entity (M.I.)
Last Name/Trust Name/Entity
—
—
—
—
Social Security Number or Taxpayer Identification Number Birth Date or Date of Trust (mm/dd/yyyy)
Address (We cannot accept a PO Box)
—
City State Zip Code
Relationship
My Spouse
My Child
My Relative
Other Percent Designated
%
First Name/Trust Name/Entity (M.I.)
Last Name/Trust Name/Entity
—
—
—
—
Social Security Number or Taxpayer Identification Number Birth Date or Date of Trust (mm/dd/yyyy)
Address (We cannot accept a PO Box)
—
City State Zip Code
Relationship
My Spouse
My Child
My Relative
Other Percent Designated
%
Total Percentage of All Contingent Beneficiaries
1
0
0
%
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Completed 23 May 2022

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