DEFINED CONTRIBUTION SUPPLEMENT
TO THE MICHIGAN UPPER PENINSULA
INTERNATIONAL BROTHERHOOD OF
ELECTRICAL WORKERS PENSION PLAN
BENEFICIARY DESIGNATION
PLAN DEATH BENEFITS
I, ______________________________________________________, SS# _________________________________
hereby designate the following as my PRIMARY BENEFICIARY under the above-named Plan:
_______________________________________________________ SS# __________________________________
Primary Beneficiary’s Name
_______________________________ _________________________________
Birth Date Relationship to me
If the Primary Beneficiary does not survive me or survives me, but dies before actual payment in full of my beneficial interest, or if there be no
named Primary Beneficiary, the remaining portion of my beneficial interest shall be paid in equal shares to such of the following
CONTINGENT BENEFICIARIES who survive me:
NAME______________________________________SS#__________________Birth Date____________ Relationship to me_____________
NAME______________________________________SS#__________________Birth Date____________ Relationship to me_____________
NAME _____________________________________SS#__________________Birth Date____________Relationship to me _____________
NAME_______________________________________SS#_________________Birth Date___________ Relationship to me______________
If none of the beneficiaries named above survive me, the remaining portion of my beneficial interest shall be distributed according to the terms
of the Plan.
This form constitutes a revocation in full of any Beneficiary designations previously made by me and may be changed or revoked by me at any
time, provided that such subsequent designations be in writing and filed with the Board of Trustees no later than 10 days after my death.
Date_______________________ Signature of Participant______________________________________
CONTINUED
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SUPPLEMENT TO MICH. U.P. IBEW PENSION PLAN
BENEFICIARY DESIGNATION
SPOUSAL CONSENT TO BENEFICIARY DESIGNATION
(For Married Participants Only)
(Your spouse must consent if you designate someone other than your spouse as your beneficiary)
As the spouse of the participant named above, I hereby consent to the above designation of a beneficiary to receive my spouse’s death benefits
under the Defined Contribution Supplement to the Michigan Upper Peninsula International Brotherhood of Electrical Workers Pension Plan.
further, I hereby acknowledge (1) that the effect of my consent may be to forfeit benefits that I would otherwise be entitled to receive upon my
spouse’s death; (2) that my spouse’s designation is not valid unless I consent to it; and (3) that my consent is irrevocable.
Date _________________ Signature of Spouse ___________________________________________
NOTE: NOTARIZATION IS REQUIRED ONLY FOR THE SPOUSE OF A MARRIED PARTICIPANT IF THE SPOUSE IS NOT THE BENEFICIARY. THE PARTICIPANT’S SIGNATURE NEED NOT BE NOTARIZED.
STATE OF ________________________)
) SS
COUNTY OF ____________________________ )
Personally came before me this ____________day of ____________________, 20_____, the above-named ____________________________
to me known to be the person who executed the foregoing Spousal Consent to Beneficiary Designation and acknowledged the same.
_________________________________________________
Notary Public, State of ______________________________
My Commission ___________________________________
(Notaries Seal)
Acknowledged and recorded on _________________________, 20_______, by the Board of Trustees
Authorized Signature_________________________________________________________________