C. AFFIRMATION AND ACKNOWLEDGEMENT BY PARTICIPANT: All of my previous beneficiary designations, ifany, are null and void. I affirm that, to the best of my knowledge, there is no court order (other than a Qualified DomesticRelations Order) that assigns any of my interest in the Plan to any other person. I hereby affirm that:[] I am not married or I have a court order recognizing my legal separation from my spouse; and if I was everpreviously married, I have a valid decree of divorce from all ex-spouses. I acknowledge that any designation made on thisform today may be invalidated upon my marriage, and agree to keep the Plan Administrator informed of any changes to mymarital status.[] I am presently legally married. I shall keep the Plan Administrator informed of any change to my marital status.Unless my spouse is the only primary beneficiary, my spouse has completed the SPOUSAL CONSENT below. If I am notyet age 35, I acknowledge that I will have to re-obtain the consent of my spouse to my naming a non-spouse primarybeneficiary when I turn age 35.I acknowledge that I need to fill out a new beneficiary designation form to change any designations made on this form.Participant’s Signature: _____________________________________Date: ______________________________Your spouse should NOT complete Section D. below if selected as 100% beneficiary above.D. SPOUSAL CONSENT: Print Name of Spouse: _________________________________________________________I hereby consent to the distribution of all (or the portion specified by my spouse on the Designation of Beneficiary Form) ofthe benefits payable from the Plan on account of the Participant’s death to the primary beneficiary named on theDesignation of Beneficiary Form. I acknowledge that (1) the effect of my consent is to cause all or a portion of the Plan’sDeath benefits paid to a beneficiary other than me, (2) that the Participant’s designation of the primary beneficiary otherthan me is not valid unless I consent to it (3) that my consent is irrevocable unless the Participant subsequently revokes hisor her waiver, in which event my consent will again be required for the Participant to name a non-spouse beneficiary. If myspouse has waived the pre-retirement surviving spouse annuity, I acknowledge that, but for my consent, all or a portion ofmy spouse’s benefits would be payable to me in the form of an annuity over my life, and I hereby irrevocably relinquishthat right; however, should the Participant revoke his of her waiver at any time, my consent will again subsequently berequired to again waive this requirement.Signature of Spouse: ____________________________________________ Date: ___________________________________Signature of Witness: ____________________________________________Date: ___________________________________Print Name of Witness: __________________________________________________________________________________[] Witness is a Plan Representative OR[] Witness is a Notary Public (Complete below):State of ________________________________County of ______________________________My Commission expires: _____________________________________________________________
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