Beneficiary Designation s1

Beneficiary Designation

Instructions:

If you are married and want your spouse to be the beneficiary, check the first box. This allows for your children to automatically become the primary beneficiaries if your spouse should die before you.

If you want to name several primary beneficiaries, check the second box; list the names, relationship, percentage each person is to receive and their social security numbers.

If you want to name secondary beneficiaries in addition to a primary beneficiary (who may or may not be your spouse), check the third box and put the primary beneficiary in the first line and the secondary beneficiary(ies) in the next set of lines.

If you want your estate/living trust to be the primary and only beneficiary, check the fourth box.

If you wish to name a charity or organization or have instructions other than the options given, check the fifth box.

NOTE: IF YOU ARE MARRIED AND DO NOT DESIGNATE YOUR SPOUSE TO RECEIVE AT LEAST 50% OF YOUR ACCOUNT, YOU MUST HAVE YOUR SPOUSE SIGN THE WAIVER AT THE END OF THIS DOCUMENT.

Please fill out and return this form to:

Dedicated Defined Benefit Services

550 North Brand Boulevard

Suite 1610

Glendale, CA 91203

Plan Name ______Defined Benefit Plan

EIN or Account Number: ______

Designation or Change of Beneficiary

(PLEASE PRINT AND COMPLETE IN FULL)

Participant Name:______Social Security No.: ______-______-______

Address:______

City:______State:______Zip:______

I hereby request that any benefit under this Plan which become payable in the event of my death be paid as set forth in the paragraph checked below.

(Complete One Paragraph Only) _____I am married _____I am not married.

____ 1. Primary

Spouse Name:______Social Security No.:______-______-______

If living at my death; if not, equally to our child or children as indicated below if more than one:

______

____ 2. One or More Primary Beneficiaries:

To the following named person(s) as are living at my death:

Name: ______Relationship: ______%: ______SSN: _____-____-_____

____ 3. Named Primary and Secondary Beneficiaries:

Primary, if living at my death:

Name: ______Relationship: ______%: ______SSN: _____-____-_____

If not living at my death, Secondary:

Name: ______Relationship: ______%: ______SSN: _____-____-_____

____ 4. Primary: Estate/Living Trust of Insured

To the executors or administrators of my estate/living trust:

____ 5. Primary: Other

______

Note for married participants:

Federal Legislation (REA) requires that your spouse be named beneficiary for at least 50% of your account unless a signed waiver is provided by your spouse.

Participant Signature: ______Date:______

Complete this form and forward the original to your Employer.

WAIVER OF BENEFITS AND SPOUSAL CONSENT TO NON-SPOUSAL BENEFICIARY OF DEATH BENEFITS

I hereby waive my right to death benefits and consent to the designation of beneficiary on the above form with full knowledge that in doing so I irrevocably give up my right to death benefits as spouse of the participant under the Plan. I understand that this waiver of my rights and consent to this election by the participant is not valid unless I consent to it, and that my consent is irrevocable unless my spouse revokes it.

Participant’s Spouse Signature:

______

Executed this ______day of ______, ______

Witnessed By:______

or______

Notary Public

Plan Representative