Full Text
FRM000-146-34012-201512-C2753 I 1 ICMA-RC • Attn: Workflow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 1-VRS-DC-PLAN1 (1-[PHONE REDACTED]) • Fax [PHONE REDACTED] rev 6/2017 DESIGNATION OF BENEFICIARY INSTRUCTIONS HYBRID DEFINED CONTRIBUTION PLANS Please provide all of the requested information for each designated beneficiary, including the date of birth and Social Security number, as this information will help ICMA-RC locate your beneficiaries. The primary beneficiary(ies) will receive your Hybrid Retirement Plan Defined Contribution plan assets upon your death. You may designate one or more persons as your primary beneficiary(ies). If none of your primary beneficiaries are alive at the time of your death, then the assets will be paid to the contingent beneficiary(ies) that you have designated. You may designate one or more persons as your contingent beneficiary(ies). Be sure to use whole percentages when designating multiple beneficiaries. If you have not designated any beneficiaries or if both the Primary and Contingent Beneficiaries are not alive at the time of your death, then the assets will be paid pursuant to the terms of the Plan Document as follows: unless otherwise directed on the Beneficiary Designation form, the beneficiary designation shall be deemed to be my surviving spouse, or if none, my children and descendants of my deceased children, per stirpes, or if none, my parents equally if both living, or if none, the duly appointed executor or administrator of my estate, or if none, the next of kin entitled to inherit under the laws of my domicile at the time of my death, as determined by the Virginia Retirement Systems. To designate additional beneficiaries, write “see attached sheet” on the primary and/or contingent beneficiary line(s) under “Name” and attach and sign a separate piece of paper with your name, plan number, Social Security number, and additional beneficiary information. Missing percentage(s) for all of your primary and/or contingent beneficiaries will result in equal allocation among beneficiaries. Beneficiary designations are invalid if percentages are given for every beneficiary, but they do not equal 100% or are expressed with fractions 331/3%). If you are naming a trust as your primary or contingent beneficiary, a complete copy of your entire trust document must be submitted with this form. ICMA-RC will not be able to honor your beneficiary designation if the entire copy of your trust document is not included. SPOUSAL CONSENT FOR MARRIED PARTICIPANTS If you live in a community property state (AZ, CA, ID, LA, NV, NM, TX, WA, or WI), your spouse is generally entitled to be the primary beneficiary for at least 50% of your account unless he or she consents to waive this right in the presence of a notary public. Failure to meet community property state law requirements with respect to your beneficiary designation may result in your beneficiary designation being invalid, and the payment of benefits to someone other than your intended beneficiary(ies). AUTHORIZATION Once you have completed this form, sign it and submit the pages to ICMA-RC. If this form is faxed ([PHONE REDACTED]) to ICMA-RC, please do not mail the original. Please be aware that designations made on this form only apply to the defined contribution component of the Hybrid Retirement Plan and do not impact designations you may make for the defined benefit component, which you must do separately. Some provisions related to voluntary contributions and the associated employer match may differ for school division employees who have elected to use an employer- sponsored hybrid 403(b). For additional information, contact your human resources office. To designate a beneficiary(ies) for the defined benefit component, you may complete and submit a Designation of Beneficiary (VRS-2) to VRS. The form is available at www.varetire.org. Be sure to keep a copy for your records. ---PAGE BREAK--- FRM000-146-34012-201512-C2753 I 2 ICMA-RC • Attn: Workflow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 1-VRS-DC-PLAN1 (1-[PHONE REDACTED]) • Fax [PHONE REDACTED] rev 6/2017 Social Security Number – – Email NOTE: Beneficiary information can also be added, changed and deleted by accessing your account online at www.varetire.org or contacting an Investor Services associate at 1-VRS-DC-PLAN1 (1-[PHONE REDACTED]). 108043 — Hybrid 401(a) Cash Match Plan 307059 — Hybrid 457 Deferred Compensation Plan DESIGNATION OF BENEFICIARY FORM HYBRID DEFINED CONTRIBUTION PLANS I 1 OF 3 This designation supersedes all prior designations. Beneficiaries will share equally if percentages are not provided and any amounts unpaid upon death will be divided equally. Primary and contingent beneficiaries must separately total 100%. The number of primary or contingent beneficiaries you may name is not limited. Attach an additional sheet if necessary. Please see instructions. BENEFICIARY DESIGNATION PARTICIPANT INFORMATION — PROVIDE NAME/SOCIAL SECURITY NUMBER AS IT CURRENTLY APPEARS ON YOUR ACCOUNT. Full Name of Participant last first m.i. Primary Beneficiary Name Date of Birth (mm/dd/yyyy) Relationship to You* Social Security Number % of Benefit 1 / / – – % 2 / / – – % 3 / / – – % *The beneficiary relationship options are spouse, non-spouse, trust, estate, and charity. Total = 100% PRIMARY BENEFICIAR(IES) Contingent Beneficiary Name Date of Birth (mm/dd/yyyy) Relationship to You* Social Security Number % of Benefit 1 / / – – % 2 / / – – % 3 / / – – % *The beneficiary relationship options are spouse, non-spouse, trust, estate, and charity. Total = 100% CONTINGENT BENEFICIAR(IES) Read the important beneficiary information in the form instructions before completing this section. Please use whole percentages and be sure the percentages total 100% when designating primary and contingent beneficiaries. HYBRID 401(A) CASH MATCH PLAN I 108043 A. Primary Beneficiary(ies) — will receive your assets upon your death. The primary beneficiary information you indicate here will supersede previously submitted information and will be used by ICMA-RC to determine the primary beneficiary(ies) entitled to all or a portion of your plan account. B. Contingent Beneficiary(ies) — will receive your assets if there is no primary beneficiary(ies) living at the time of your death. The contingent beneficiary information you indicate here will supersede previously submitted information and will be used by ICMA-RC to determine the contingent beneficiary(ies) entitled to all or a portion of your plan account. Date (mm/dd/yyyy) / / ---PAGE BREAK--- FRM000-146-34012-201512-C2753 I 3 ICMA-RC • Attn: Workflow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 1-VRS-DC-PLAN1 (1-[PHONE REDACTED]) • Fax [PHONE REDACTED] rev 6/2017 IF YOU LIVE IN THE COMMONWEALTH OF VIRGINIA, THIS SECTION IS NOT APPLICABLE. Spousal Consent to Name a Non-Spousal Primary Beneficiary(ies): By signing below, I hereby voluntarily consent to the beneficiary designation made by my spouse and waive my designation as sole primary beneficiary. I understand that the effect of this designation is to cause some or all of my spouse’s death benefit to be paid to someone other than me; each beneficiary designation is not valid unless I consent to it; and my consent (signature) must be witnessed by a notary public. Signature of Participant’s Spouse Date / / Print Name of Participant’s Spouse SPOUSAL CONSENT IS REQUIRED TO BE WITNESSED BY: Notary Public Subscribed and sworn before me this day of (month), 20 Notary Signature Commission Expiration Date / / Registration Number: BENEFICIARY DESIGNATION (CONTINUED) DESIGNATION OF BENEFICIARY FORM I 2 OF 3 Your request cannot be processed without a Notary Public Signature and Seal. Seal Or Stamp HYBRID 457 DEFERRED COMPENSATION PLAN I 307059 PLEASE CHECK HERE IF YOU WOULD LIKE TO DESIGNATE THE SAME PRIMARY AND CONTINGENT BENEFICIARIES THAT YOU LISTED ON PAGE 1 — YOU DO NOT NEED TO COMPLETE THIS SECTION. A. Primary Beneficiary(ies) — will receive your assets upon your death. The primary beneficiary information you indicate here will supersede previously submitted information and will be used by ICMA-RC to determine the primary beneficiary(ies) entitled to all or a portion of your plan account. Primary Beneficiary Name Date of Birth (mm/dd/yyyy) Relationship to You* Social Security Number % of Benefit 1 / / – – % 2 / / – – % 3 / / – – % *The beneficiary relationship options are spouse, non-spouse, trust, estate, and charity. Total = 100% PRIMARY BENEFICIAR(IES) Contingent Beneficiary Name Date of Birth (mm/dd/yyyy) Relationship to You* Social Security Number % of Benefit 1 / / – – % 2 / / – – % 3 / / – – % *The beneficiary relationship options are spouse, non-spouse, trust, estate, and charity. Total = 100% CONTINGENT BENEFICIAR(IES) B. Contingent Beneficiary(ies) — will receive your assets if there is no primary beneficiary(ies) living at the time of your death. The contingent beneficiary information you indicate here will supersede previously submitted information and will be used by ICMA-RC to determine the contingent beneficiary(ies) entitled to all or a portion of your plan account. SPOUSAL CONSENT — ONLY APPLICABLE TO PARTICIPANTS RESIDING IN AZ, CA, ID, NV, NM, TX, WA, OR WI Name (Last, First, M.I.) Social Security Number – – Plan Number 108043 I 307059 Date (mm/dd/yyyy) / / ---PAGE BREAK--- FRM000-146-34012-201512-C2753 I 4 ICMA-RC • Attn: Workflow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 1-VRS-DC-PLAN1 (1-[PHONE REDACTED]) • Fax [PHONE REDACTED] rev 6/2017 DESIGNATION OF BENEFICIARY FORM I 3 OF 3 REQUIRED PARTICIPANT SIGNATURE This designation is effective when signed, dated and received by ICMA-RC (“Service Provider”) at the address below prior to the death of the participant. If I name more than one beneficiary in either category, the surviving beneficiaries in that category will share equally unless otherwise indicated. I have the right to change the beneficiary. If any information is missing, additional information may be required prior to recording my beneficiary designation. If my primary and contingent beneficiaries predecease me or I fail to designate beneficiaries, amounts will be paid pursuant to the terms of the Plan Document as follows: unless otherwise directed on the Beneficiary Designation form, the beneficiary designation shall be deemed to be my surviving spouse, or if none, my children and descendants of my deceased children, per stirpes, or if none, my parents equally if both living, or if none, the duly appointed executor or administrator of my estate, or if none, the next of kin entitled to inherit under the laws of my domicile at the time of my death, as determined by the Virginia Retirement Systems. I have completed, understand and agree to all pages of this Beneficiary Designation form. I understand that the Service Provider is required to comply with the regulations and requirements of the Office of Foreign Assets Control, Department of the Treasury (“OFAC”). As a result, the Service Provider cannot conduct business with persons in a blocked country or any person designated by OFAC as a specially designated national or blocked person. For more information, please access the OFAC website at: http://www.ustreas. gov/offices/eotffc/ofac. Participant Signature Date / / SEND ORIGINAL TO ICMA-RC: ICMA-RC Attn: Workflow Management Team P.O. Box 96220 Washington, DC 20090-6220 Fax Number: [PHONE REDACTED] Website: www.varetire.org Name (Last, First, M.I.) Social Security Number – – Plan Number 108043 I 307059 Date (mm/dd/yyyy) / /