Page 1 of 4
301 CalSavers (Rev. 6/2019) ©2019 Ascensus, LLC
1. IRA OWNER INFORMATION (All fields required)
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)
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
Page 2 of 4
301 CalSavers (Rev. 6/2019) ©2019 Ascensus, LLC
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
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 4
301 CalSavers (Rev. 6/2019) ©2019 Ascensus, LLC
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
%
Check here if additional beneficiaries are listed on an attached Beneficiary Designation Addendum.
Total number of addendums attached to this IRA __________
Page 4 of 4
301 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.
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.
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.
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.
Signature of Notary Public Date (mm/dd/yyyy)
Notary Public’s Name (First, Middle Initial, Last)
My commission expires:
Date (mm/dd/yyyy)
Notary to Place Seal Here