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DRS D 117 (R 12/10) Page 1 of 2 BENEFICIARY DESIGNATION I understand if I select more than one primary beneficiary or more than one contingent beneficiary, the total percentage(s) for each category must add up to 100% (use whole numbers, for example 50% and 50% or 66% and 34%). I wish to designate the following beneficiary(ies) in accordance with the provisions of the Plan: T Primary Beneficiary Relationship Percentage % Social Security Number Beneficiary Name (Last, First, Middle) Gender c M c F Mailing Address City State ZIP Date of Birth (mm/dd/yyyy) Check One c Primary c Contingent Relationship Percentage % Social Security Number Beneficiary Name (Last, First, Middle) Gender c M c F Mailing Address City State ZIP Date of Birth (mm/dd/yyyy) Check One c Primary c Contingent Relationship Percentage % Social Security Number Beneficiary Name (Last, First, Middle) Gender c M c F Mailing Address City State ZIP Date of Birth (mm/dd/yyyy) Check One c Primary c Contingent Relationship Percentage % Social Security Number Beneficiary Name (Last, First, Middle) Gender c M c F Mailing Address City State ZIP Date of Birth (mm/dd/yyyy) I direct any accumulated deferrals in my deferred compensation account to be paid, in the percentages indicated above, to any primary beneficiaries who survive me. If none survive, such monies will be paid, in the percentages indicated, to any contingent beneficiaries who survive me. Completion of this form revokes any prior designations I have made. Participant Signature Date BENEFICIARY DESIGNATION DEFERRED COMPENSATION PROGRAM PO Box 40931 Olympia, WA 98504-0931 w www.drs.wa.gov/dcp Toll Free: 1-[PHONE REDACTED] w TTY: 1-[PHONE REDACTED] w Fax: [PHONE REDACTED] PARTICIPANT INFORMATION Social Security Number Employer Name Daytime Phone Number ( ) Participant Name (Last, First, Middle) Date of Birth (mm/dd/yyyy) Evening Phone Number ( ) Mailing Address City State ZIP Gender c M c F Important: Before completing this form, please read instructions on page 2. *DRSD117* Clear Form ---PAGE BREAK--- DRS D 117 (R 12/10) Page 2 of 2 BENEFICIARY DESIGNATION INSTRUCTIONS This form is to be used to designate or change the beneficiary(ies) who will receive the accumulated deferrals from your deferred compensation account in the event of your death. To make your designation(s), complete these steps (type or print): 1. Complete all personal information in the top section of the form. 2. Indicate who you wish to make either a primary or a contingent beneficiary by marking the appropriate box next to each person's name. • A primary beneficiary will receive the balance of the deceased participant's account, if they survive the participant by 30 days. If selecting more than one primary beneficiary, the total percentages for all primary beneficiaries must equal 100%, in whole numbers 50% and 50% or 66% and 34%). • A contingent beneficiary will receive the balance of the deceased participant's account if no primary beneficiary is still living at the time of the participant's death. If selecting more than one contingent beneficiary, the total percentages for all contingent beneficiaries must equal 100%, in whole numbers 50% and 50% or 66% and 34%). Provide each beneficiary’s percentage, Social Security number, full name, mailing address, date of birth, relationship and gender. To name a trust as beneficiary, indicate name of trust and date trust was established. A copy of the trust document should be provided. To name your estate as beneficiary, write my estate. In the event of participant’s death, distribution to a minor requires the following before distribution can occur: • Guardian: A copy of court documents showing the name, address and telephone number of minor’s court appointed guardian, or • Custodian: A copy of the trust or other documents showing power of appointment under the WA Uniform Transfers to Minors Act. 3. Sign and date. BENEFICIARY DESIGNATION EXAMPLE I understand if I select more than one primary beneficiary or more than one contingent beneficiary, the total percentage(s) for each category must add up to 100% (use whole numbers, for example 50% and 50% or 66% and 34%). I wish to designate the following beneficiary(ies) in accordance with the provisions of the Plan: T Primary Beneficiary Relationship Husband Percentage 100 % Social Security Number ‑ ‑ Beneficiary Name (Last, First, Middle) Doe, John Mark Gender c M c F Mailing Address 3232 Street Way City Olympia State WA ZIP 98502 Date of Birth (mm/dd/yyyy) 7/8/1945 Check One c Primary c Contingent Relationship Daughter Percentage 50 % Social Security Number ‑ ‑ Beneficiary Name (Last, First, Middle) Doe, Jane Sarah Gender c M c F Mailing Address 1111 Boulevard Court City Federal Way State WA ZIP 98321 Date of Birth (mm/dd/yyyy) 10/11/1978 Check One c Primary c Contingent Relationship Son Percentage 50 % Social Security Number ‑ ‑ Beneficiary Name (Last, First, Middle) Doe, George Lawrence Gender c M c F Mailing Address 300 W. Road Street City Spokane State WA ZIP 99111 Date of Birth (mm/dd/yyyy) 3/31/1976 X X X X X