RLF Enrollment - Web Book - Ready - Flipbook - Page 23
PROFIT SHARING PLAN FOR THE EMPLOYEES OF
ROGERS, LOVELOCK & FRITZ, INC.
BENEFICIARY DESIGNATION FORM
Please read these instructions completely before filing out this form.
If naming only one beneficiary in either category (primary or
contingent), the share will automatically be 100%.
If naming more than one beneficiary in a category, indicate an
ownership share for each (in percent, not dollars). Make sure the
percentages total 100% exactly. If no shares are indicated, equal
percentages will be assigned to any beneficiaries in that category
who are alive at the time of your death (or, if you checked “per
stirpes”, to the survivors of those beneficiaries).
To designate more than three beneficiaries in either category, use
a copy of this page or attach a sheet with all applicable beneficiary
information, your Social Security Number, your signature, and the
date.
To change a designation in the future, such as adding or removing
a beneficiary or changing your “per stirpes” contact, complete a new
form.
Per Stirpes: To have a beneficiary’s share pass to his/her
descendants, should the beneficiary die before you, provide “per
stirpes” information (including contact information), in consultation
with an estate planning attorney. By selecting YES for “per stirpes”,
you indicate that the share of any individual beneficiary who
predeceases you will pass to his or her descendants, as defined by the
laws of your state in force at the time of your death. If you do not
provide a “per stirpes” contact name, or if the contact is unavailable
to act, the contact will be your executor.
To designate your estate as beneficiary, enter “Estate” as the
name.
PARTICIPANT NAME: _______________________________________________________________________________________________________
SOCIAL SECURITY #: _______________________________ DATE OF BIRTH: _______________ DATE OF HIRE:____________________
A. PRIMARY BENEFICIARY: I hereby designate the following person or persons and/or trusts as beneficiaries to receive
any benefits that become payable from the Plan as a result of my death prior to the full commencement of my Plan benefits:
Name of Beneficiary
Social Security Number/Taxpayer ID Number
Relationship to You
Date of Birth
Name of Beneficiary
Social Security Number/Taxpayer ID Number
%
Per Stirpes?
Yes
No
%
Per Stirpes?
Yes
No
%
Per Stirpes?
Yes
No
Relationship to You
Date of Birth
Name of Beneficiary
Social Security Number/Taxpayer ID Number
Percentage
Percentage
Relationship to You
Date of Birth
Percentage
B. CONTINGENT BENEFICIARY: In the event a beneficiary designated above fails to survive me, I hereby designate the
following person or persons and/or trusts as contingent beneficiaries for that portion of benefits:
Name of Beneficiary
Social Security Number/Taxpayer ID Number
Relationship to You
Date of Birth
Name of Beneficiary
Social Security Number/Taxpayer ID Number
%
Per Stirpes?
Yes
No
%
Per Stirpes?
Yes
No
%
Per Stirpes?
Yes
No
Relationship to You
Date of Birth
Name of Beneficiary
Social Security Number/Taxpayer ID Number
Percentage
Percentage
Relationship to You
Date of Birth
Percentage
