Diocese Enrollment - Web Book - Ready - Flipbook - Page 22
Social Security Number/Taxpayer ID Number
Street Address
Date of Birth
City
Name of Beneficiary
Social Security Number/Taxpayer ID Number
Street Address
Percentage
%
Per Stirpes?
Yes
No
Zip Code
%
Per Stirpes?
Yes
No
Zip Code
State
Relationship to You
Date of Birth
City
Percentage
State
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 preretirement 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: _____________________________________________________________