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Appendix B: Forms
481
________________________________________
Signature of Participant
Receipt of the above beneficiary designation form is hereby acknowledged this _____ day of
____________________, 20 _____.
________________________________________
Name of Custodian or Trustee
By: _______________________________ [Title]
2.2 Master Beneficiary Designation Form: Qualified Plan
DESIGNATION OF BENEFICIARY
TO:
__________________________________________
Name of Custodian or Trustee of the Account
FROM: __________________________________________
Name of Participant
RE:
__________________________________________
Name of Retirement Plan
I.
Definitions
The following words, when used in this form and capitalized, shall have the meaning indicated
in this Section.
“Administrator” means the Plan Administrator or Trustee named above, and its successors in
such office.
“Beneficiary” means any person entitled to receive benefits under the Plan as a result of my
death (or as a result of the death of another Beneficiary).
“Contingent Beneficiary” means the person(s) I have designated in this form to receive the
Death Benefit if my Primary Beneficiary does not survive me (or disclaims the benefits).
“Death Benefit” means all benefits payable under the Plan on account of my death.
The “Personal Representative” of any person means the duly appointed guardian or
conservator of such person, or executor or administrator of such person’s estate, who is serving
as such at the applicable time.
“Plan” means the qualified retirement plan or other retirement arrangement described at the
beginning of this form.
“Primary Beneficiary” means the person(s) designated in this form to receive benefits under
the Plan on account of my death.
II. Designation of Beneficiary
[Here insert the name(s) of the primary and contingent beneficiary(ies). This section must be
drafted by the estate planning attorney; see sample inserts in Part 3 of this
Appendix B .If the