Fill - Free fillable form to indicate the beneciary or beneciaries that PDF form

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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)

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Telephone Number (In case we have a question about your Account)

BENEFICIARY DESIGNATION

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. Use this

form to indicate the beneﬁciary or beneﬁciaries that will receive your assets in the event of your death. If you need to add more beneﬁciaries

than will ﬁt on this form, complete the Beneﬁciary Designation Addendum and submit it with this form. If you do not designate a beneﬁciary or

if all your primary and contingent beneﬁciaries predecease you, in the event of your death, your IRA will be paid to your spouse. If you do not

have a spouse, it will be paid to your estate.

This beneﬁciary designation overrides all previous designations for this IRA.

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

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2. BENEFICIARY DESIGNATION (All fields required)

I designate that upon my death, the assets in this account shall be paid to the beneficiary or beneficiaries designated below. The interest of any

beneficiary that predeceases me shall terminate completely, and such interest shall be allocated by increasing the percentage interest of any

remaining beneficiaries on a pro rata basis. If no beneficiaries are named or all of my primary and contingent beneficiaries predecease me, my

spouse will be my beneficiary. If I do not have a spouse, my estate will be my beneficiary.

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

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Social Security Number or Taxpayer Identification Number Birth Date or Date of Trust (mm/dd/yyyy)

Address (We cannot accept a PO Box)

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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

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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

Check here if additional beneficiaries are listed on an attached Beneficiary Designation Addendum.

Total number of addendums attached to this IRA __________

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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.

I designate the individuals or entities named above as my primary and/or contingent beneficiaries of this IRA. I hereby revoke all prior beneficiary

designations, if any, made by me.

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Signature of IRA Owner Date (mm/dd/yyyy)

4. SPOUSAL CONSENT

Skip this section unless you live in one of the following states: Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico,

Texas, Washington, or Wisconsin. If you reside in one of these states, are married at the time of your death, and designate someone other

than or in addition to your spouse, you must obtain your spouse’s consent or your IRA may be payable to your spouse upon your death.

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 beneficiary other than or in addition to my spouse, my spouse may need

to 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 financial obligations. Because of the important tax consequences of giving up my interest in this IRA, I have been advised to see a qualified

tax professional.

I hereby relinquish any interest that I may have in this IRA and consent to the beneficiary designation indicated above. I assume full responsibility

for any adverse consequences that may result. Note: Do not sign below until you are in the presence of the authorized notary providing the

notary service.

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Signature of Spouse Date (mm/dd/yyyy)

(Your signature must be notarized. See below. We cannot accept a signature guarantee in place of a notary’s seal.)

STATE OF

ss.:

COUNTY OF

This document was acknowledged before me on (date) by (name of

Spouse), who certifies the correctness of the signature of such spouse.

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Signature of Notary Public Date (mm/dd/yyyy)

Notary Public’s Name (First, Middle Initial, Last)

My commission expires:

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Date (mm/dd/yyyy)

Notary to Place Seal Here

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