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Oakland County Deferred Compensation Plans Fidelity Investments Beneficiary Form

1. YOUR INFORMATION Please use a black pen and print clearly in CAPITAL LETTERS.

This beneficiary designation applies to:

Deferred Compensation 457 (82953) and County Match Plan (72438)

OR

Deferred Compensation 457 only (82953) OR

County Match Plan only (72438)

Social Security #:

Date of Birth:

First Name:

Last Name:

Street Address:

Address Line 2:

City:

State:

Zip:

Daytime Phone:

Evening Phone:

Name of Employer: Oakland County

I am:

Single

OR

Married

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