I.B.E.W. Local Union # 812 Annuity Fund Beneficiary Designation

Section 1: Census Information (Print)

Name: ________________________________________S.S.#: _________________________________

Street: ______________________________________________________________________________

City: ______________________________________ State: _______________Zip: __________________

Telephone:(_____)___________________________Date of Birth: _____________________________

Date of Initiation: _________________________

Section 2: Beneficiary Designation (Print)

Primary Beneficiary Name: ___________________________________________________________

SS#: ________________________________________Date of Birth: ____________________________

Address: _____________________________________________________________________________

City: _________________________________________State: __________________Zip: _____________

Relationship: _________________________________________________________________________

Contingent Beneficiary: _____________________________Relationship:_______________________

Section 3: Member's Verification and Signature:

The information listed above is complete and correct. I designate the beneficiary indicated above.

Signature: ______________________________________________Date: __________________________

Section 4: Spousal Consent

I declare that I am the member's spouse and I voluntarily consent to the non-spouse beneficiary designation that appears above. I understand and acknowledge that this designation will cause pre-retirement death benefits to be paid to someone else instead of me.

Spouse's Signature:_____________________________________Date:___________________________

Notarization or Plan Representative witness

State of:

This Instrument was signed before me on:                                            Notary Seal:

By:

Notary Signature:

Notary Public for:

My Commission Expires: