Life and Death Planning for Retirement Benefits

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participant is married, spousal consent is normally required if anyone other than the spouse is

named as beneficiary. See

]

III. Other Provisions [dispense with any of these that are not appropriate in view of the

choice of beneficiary or that are not necessary because already covered in the plan documents

governing the benefits]

3.01 Honoring Disclaimers. If a Beneficiary disclaims all or any portion of any interest

in the Death Benefit to which such Beneficiary would otherwise be entitled under the foregoing

provisions hereof, by means of a written disclaimer delivered to the Administrator within nine

months after my death, then that Beneficiary shall be deemed (as to the interest so disclaimed)

to have predeceased me, the interest so disclaimed shall pass as if such Beneficiary had

predeceased me, and the Beneficiary who takes the interest so disclaimed shall be deemed to

be my beneficiary under the Plan for all purposes. This provision shall not be construed to

prevent an interest disclaimed by my spouse from passing to my spouse by other means.

3.02 Information to be provided to Personal Representative. The Administrator shall

provide to my Personal Representative any information such representative shall request in

connection with the performance of such representative’s duties (including the preparation of

any tax return) regarding the benefits, the Plan, and the Beneficiary(ies), including information

as to matters prior to such representative’s appointment, and including copies of Plan

documents and returns, to the same extent and on the same terms that such information would

have been provided to me had I requested it. Any Beneficiary, by accepting benefits hereunder,

shall be deemed to have consented to the release of information to my Personal Representative

as provided in the preceding sentence.

3.03 Governing Law. The law of the State of _____________ shall apply solely for

the purpose of interpreting my intent as expressed in this Designation of Beneficiary form.

This provision is not intended to amend or supercede any governing law provision in the Plan

with respect to the interpretation and administration of the Plan.

Signed this _____ day of ____________________, 20 _____.

________________________________________

Signature of Participant

Receipt of the above beneficiary designation form is hereby acknowledged this _____ day of

____________________, 20 _____.

________________________________________

Name of Custodian or Trustee

By: _______________________________ [Title]

2.3 Additional Clauses for Master Beneficiary Designations

These clauses can be added to the Master Beneficiary Designations (Forms 2.1 and 2.2) if

needed. Use 3.04 if there is any possibility that a minor may become a beneficiary of the plan or

account. Use 3.05 if there is any possibility that there could be multiple beneficiaries of the plan