City Beverages Enrollment - Web Book - Ready - Flipbook - Page 22
C. AFFIRMATION AND ACKNOWLEDGEMENT BY PARTICIPANT: All of my previous beneficiary designations, if
any, are null and void. I affirm that, to the best of my knowledge, there is no court order (other than a Qualified Domestic
Relations Order) that assigns any of my interest in the Plan to any other person. I hereby affirm that:
[
] I am not married or I have a court order recognizing my legal separation from my spouse; and if I was ever
previously married, I have a valid decree of divorce from all ex-spouses. I acknowledge that any designation made on this
form today may be invalidated upon my marriage, and agree to keep the Plan Administrator informed of any changes to my
marital status.
[
] I am presently legally married. I shall keep the Plan Administrator informed of any change to my marital status.
Unless my spouse is the only primary beneficiary, my spouse has completed the SPOUSAL CONSENT below. If I am not
yet age 35, I acknowledge that I will have to re-obtain the consent of my spouse to my naming a non-spouse primary
beneficiary when I turn age 35.
I acknowledge that I need to fill out a new beneficiary designation form to change any designations made on this form.
Participant’s Signature: _____________________________________
Date: ______________________________
Your spouse should NOT complete Section D. below if selected as 100% beneficiary above.
D. SPOUSAL CONSENT: Print Name of Spouse: _________________________________________________________
I hereby consent to the distribution of all (or the portion specified by my spouse on the Designation of Beneficiary Form) of
the benefits payable from the Plan on account of the Participant’s death to the primary beneficiary named on the
Designation of Beneficiary Form. I acknowledge that (1) the effect of my consent is to cause all or a portion of the Plan’s
Death benefits paid to a beneficiary other than me, (2) that the Participant’s designation of the primary beneficiary other
than me is not valid unless I consent to it (3) that my consent is irrevocable unless the Participant subsequently revokes his
or her waiver, in which event my consent will again be required for the Participant to name a non-spouse beneficiary. If my
spouse has waived the pre-retirement surviving spouse annuity, I acknowledge that, but for my consent, all or a portion of
my spouse’s benefits would be payable to me in the form of an annuity over my life, and I hereby irrevocably relinquish
that right; however, should the Participant revoke his of her waiver at any time, my consent will again subsequently be
required to again waive this requirement.
Signature of Spouse: ____________________________________________ Date: ___________________________________
Signature of Witness: ____________________________________________Date: ___________________________________
Print Name of Witness: __________________________________________________________________________________
[
] Witness is a Plan Representative OR
[
] Witness is a Notary Public (Complete below):
State of ________________________________
County of ______________________________
My Commission expires: _____________________________________________________________
