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Retirement Services Participant Data Change Please complete the section(s) that apply to your request (any incomplete forms will be returned) ( ) Active Participant ( ) Retiree or Survivor ( ) Terminated Participant Section I: Personal Information Name: Employer/Jurisdiction: Social Security Number: Phone Number: Email Address: Section II: Name Change (please submit a copy of the appropriate court document for your name change) ( ) Name Changed From: Section III: Address Change ( ) New Address: ( ) Old Address: Section IV: Beneficiary Information (if not checked, applies to all Plans) ( ) 401(a) Defined Contribution Plan ( ) Deferred Compensation Plan ( ) Defined Benefit Plan You may use this form to designate the same beneficiary(ies) for all plans in which you participant. If you wish to designate different beneficiary(ies) for each plan in which you participant, you must complete a separate form for each plan If you name more than one primary or contingent beneficiary, the to Beneficiary” for the category must equal 100% The “Percent to Beneficiary” can be split up to two decimal points (Example: 33.33%) The beneficiary(ies) designated on this form relates only to the receipt of Lump Sum or Balance of Period Certain Benefits payable under the Defined Benefit Pension Plan. I hereby designate the following beneficiary(ies) to receive any death benefits payable under the referenced retirement plan(s), still reserving the privilege of future changes with the exception of the contingent/survivor benefit for the DB Plan. As a participant, I do hereby revoke any previous beneficiary information, and specify the below named persons as my beneficiary(ies). Primary Beneficiary Name: Date of Address: Relationship to Percent to PLEASE CHECK PRIMARY OR CONTINGENT FOR THE ADDITONAL BENEFICIARIES (if more space is needed, an additional sheet may be attached to this form) ( ) PRIMARY ( ) CONTINGENT Name: Address: Relationship to Date of Percent to ( ) PRIMARY ( ) CONTINGENT Name: Address: Relationship to Date of Percent to If more than one primary beneficiary is designated, settlement will be made to each in equal shares unless otherwise specified above. If primary beneficiary(ies) does not survive me, settlement will be made to the contingent beneficiary(ies). If no designated beneficiary survives me, settlement will be made as designated by the Plan documents. Signed: Required Witness (must not be listed as a beneficiary) Return to: ACCG Retirement Services, 12195 Hwy 92 Suite 114-392 Woodstock, GA 30188 Fax to (770) 563-9356 Phone (770) 952-5225 or (800) 736-7166 SIGN