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MRP4 Designation of Beneficiary |
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CONVERGE RETIREMENT PLAN
DESIGNATION OF BENEFICIARY
PARTICIPANT'S NAME _________________________________________________________
MARITAL STATUS ________ SOCIAL SECURITY NUMBER ________/______/_____________
I wish to designate the following as my beneficiary(ies) to receive any death benefits that may become due under the plan on account of my death. I hereby revoke any previous designations of beneficiaries I may have made.
THE PRIMARY BENEFICIARY OR BENEFICIARIES SHALL BE:
1) Name _______________________________Relationship to me __________________
Trustee (if applicable) _______________________________________________________________________
Date of Trust (if applicable) ____________________________________
Address: ________________________________________________________________
City: _______________________________ State: ______ Zipcode: _______________
Percentage ________
2) Name _______________________________Relationship to me __________________
Address: ________________________________________________________________
City: ______________________________ State: ______ Zipcode: ________________
Percentage __________
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THE SECONDARY BENEFICIARY OR BENEFICIARIES SHALL BE:
1) Name _______________________________Relationship to me __________________
Address: _______________________________________________________________
City: _______________________________ State: ______ Zipcode: _______________
Percentage ___________
2) Name _______________________________Relationship to me __________________
Address: _______________________________________________________________
City: _______________________________ State: ______ Zipcode: _______________
Percentage ___________
3) Name _______________________________Relationship to me __________________
Address: _______________________________________________________________
City: _______________________________ State: ______ Zipcode: _______________
Percentage ___________
4) Name _______________________________Relationship to me __________________
Address: _______________________________________________________________
City: _______________________________ State: ______ Zipcode: _______________
Percentage ___________
___________________________________________ _____________
Participant's Signature Date
MRP4
06/09
SPOUSE'S CONSENT (Married Participants Only)
If other than the spouse is named as primary beneficiary to receive 100% of your death benefits, the spouse must consent and sign this form in the presence of a notary public or a plan representative.
I hereby agree to the above designated primary beneficiary(ies).
_______________________________ ________________________________
Spouse's Signature Date
WITNESSED BY:
_______________________________ ________________________________
Plan Representative Date
State of ____________________
County of ___________________
On this _____________ day of __________________, 20____, the above named spouse ______________________________ personally appeared before me who acknowledges himself/herself to be the spouse of _________________________ and that as such spouse he/she executed the Spouse's Consent agreeing to the above designated beneficiary(ies).
In witness whereof I hereunto set my hand.
Notary Public ___________________________
SEAL
My Commission Expires ___________________
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