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2. DESIGNATING YOUR BENEFICIARY(IES)

Please check here if you have more than three primary or contingent beneficiaries.

Primary Beneficiary(ies)

I hereby designate the person(s) named below as primary beneficiary(ies) to receive payment of the value of my account(s) under the plan upon my death.

1. Individual or Trust Name:

Percentage:

%

Date of Birth or Trust Date:

Relationship to Applicant:

Spouse

OR

Trust

OR

Other

2. Individual or Trust Name:

Percentage:

%

Date of Birth or Trust Date:

Relationship to Applicant:

Spouse

OR

Trust

OR

Other

3. Individual or Trust Name:

Percentage:

%

Date of Birth or Trust Date:

Relationship to Applicant:

Spouse

OR

Trust

OR

Other

Total: = 100%

Contingent Beneficiary(ies)

If there is no primary beneficiary(ies) living at the time of my death, I hereby specify that the value of my account is to be distributed to my contingent beneficiary(ies) listed below. Please note: Your primary beneficiary cannot be your contingent beneficiary.

1. Individual or Trust Name:

Percentage:

%

Date of Birth or Trust Date:

Relationship to Applicant:

Spouse

OR

Trust

OR

Other

2. Individual or Trust Name:

Percentage:

%

Date of Birth or Trust Date:

Relationship to Applicant:

Spouse

OR

Trust

OR

Other

3. Individual or Trust Name:

Percentage:

%

Date of Birth or Trust Date:

Relationship to Applicant:

Spouse

OR

Trust

OR

Other

Total: = 100%

Payment to contingent beneficiary(ies) will be made according to the rules of succession described in the instructions.

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