Beneficiary Designation Form

Designation of Beneficiary Form

EKG Security, Inc. Retirement Plan
INSTRUCTIONS FOR DESIGNATION OF BENEFICIARY
1. You may name anyone you want as beneficiary. However, if you are married (or separated) and your spouse is designated to receive less than 100% of your account as a Primary Beneficiary, then your spouse must consent to your designation by completing the section "Consent of Spouse". Your spouse's signature must be witnessed by a notary.
2. If you want to name more than one Primary beneficiary, enter their names without numbering or use of words "and/or". In the event your Primary beneficiary(ies) pre-deceases you, you might want to designate a Secondary beneficiary. (You should know that, in most cases, a guardian must be appointed by court action before payment of a benefit can be made to a minor.)
3. Show a beneficiary's own full name, for example, "Mary J. Smith", not "Mrs. John E. Smith".
4. Sign the form using your signature you normally use on official documents, and enter the date of signing.
5. Be sure to complete a new beneficiary designation in the event of your marriage or divorce; failure to do so may invalidate your prevous designation or result in payments of benefits to unintended recipients.
6. If any beneficiary dies before you, you should file a new beneficiary designation unless you have named more than one beneficiary and you are satisfied with the manner in which the old designation will operate, as indicated on the form.
7. If no beneficiary designation is in effect at the time of your death, the beneficiary will be your spouse if you are married. If you are not married at the time of your death, the beneficiary will be in accordance with the Plan document.
PARTICIPANT INFORMATION
Employee Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
Date of Birth

MonthDayYear
Date
I hereby revoke any Designation of Beneficiary I may previously have made under the above Plan and designate the following as my Beneficiary(ies) under the Plan:

Primary Beneficiary(ies)

	Name	Relationship	SSN	% Share
Name
Name
Name
Name

Contingent Beneficiary(ies)

	Name	Relationship	SSN	% Share
Name
Name
Name
Name

CURRENT MARITAL STATUS (check one)

I am not married. I understand that if I become married in the future, this form automatically ceases to apply and I should file a new Designation of Beneficiary.I am married. If my spouse is not the only Primary Beneficiary, my spouse has signed the consent form. (If consent of your spouse cannot be obtained, e.g. cannot be located or is incapacitated, contact your employer for information about possible alternatives.) I understand that if my marital status changes, this Designation will nevertheless remain in effect until I file a new Designation.
Participant Signature

Clear
Date

MonthDayYear
Date
CONSENT OF SPOUSE
IF YOU ARE CHOOSING A BENEFICIARY OTHER THAN YOUR SPOUSE, THIS PORTION OF THE FORM MUST BE PRINTED AND SIGNED IN THE PRESENCE OF A NOTARY.

CONSENT OF SPOUSE:

I consent to the withdrawal that my spouse has requested and which is described in this request. I understand that this consent is irrevocable and that the subsequent granting of this withdrawal could, under some circumstances, have the effect of reducing any benefit that could otherwise become payable to me after my spouse's (Employee Participant) death if I survive him (or her).
Spouse's Signature
Date

MonthDayYear
Date
TO NOTARY: This notarization must be properly executed in your presence in order to be valid. Your failure to do so may result in substantial liability to you.

State of______________________________________

County of ____________________________________

I, ___________________________________________________, a notary public

in and for said county and state, DO HEREBY CERTIFY

that_______________________ whose name is subscribed above, appeared

before me this_____________________ day of

____________________________, 20______________, executed this Consent of

Spouse Statement, and acknowledged to me that he/she did so as a voluntary act.

___________________________________________

Notary Public

My commission expires__________________________, 20_________________.

(Seal)
Should be Empty:

Designation of Beneficiary Form

PARTICIPANT INFORMATION

CONSENT OF SPOUSE