Estate Beneficiary Designations

ESTATE BENEFICIARY DESIGNATIONS

Recitals

WHEREAS, the undersigned Owner is the legal owner of certain accounts, policies, and other assets described in this designation and desires to designate beneficiary(ies) for the disposition of such assets upon the Owner's death; and

WHEREAS, the Owner intends that this Estate Beneficiary Designations form govern the distribution of the assets specifically listed in Section "Designated Assets" below, to the extent permitted by applicable contract terms and governing law; and

WHEREAS, the Owner desires to confirm the Owner's current primary and contingent beneficiary designations and related distribution instructions, and to establish administrative procedures for the effectuation, revocation, or amendment of such designations.

Owner Information

Designated Assets

The Owner hereby designates the following asset(s) for the beneficiaries named below. For each listed asset, include the account or policy number and indicate whether this designation supersedes prior designations for that asset.

Primary Beneficiaries (Asset 1)

Primary beneficiary designations for Asset 1. Total percentage allocated among primary beneficiaries must equal 100% unless otherwise indicated.

Percentage or specific amount to this beneficiary:

Percentage or specific amount to this beneficiary:

Contingent Beneficiaries (Asset 1)

Contingent beneficiaries receive the asset only if all primary beneficiaries predecease the Owner or are otherwise unable to accept.

Percentage or specific amount to this contingent beneficiary:

Distribution Instructions (Payment Terms)

The Owner specifies the following terms for distribution of proceeds and handling of costs, taxes, and claims. Distributions shall be made in accordance with account/policy contract terms; provided, where multiple distributions are required the following schedule and conditions shall apply.

Late payment or failure to timely distribute amounts owed under this designation may result in interest charged at a rate of from the date the amounts became due until paid.

Term and Termination

This designation is effective on the Effective Date below and remains in effect until revoked or amended in writing by the Owner in accordance with the procedure set forth in this document or by operation of law.

Effective Date:

Owner may revoke or amend this designation by delivering a signed written notice to the custodian, insurer, or other applicable asset holder. Notice of revocation or amendment must be delivered at least days prior to the effective date of the change to be honored by the receiving institution, unless a shorter period is accepted by the institution in its sole discretion.

Designation for Minor Beneficiaries and Trusts

If a designated beneficiary is a minor at the time distribution is payable, the Owner directs that distribution be held in trust for the minor and managed by the Trustee named below until the minor attains the age designated below, unless otherwise required by applicable law or institution rules.

Age at which minor receives full distribution:

Revocation and Amendment Procedure

Any revocation or amendment of this designation must be executed in writing by the Owner and provided to each custodian or issuer of a designated asset. The Owner acknowledges that an institution may require its own form or procedures to effectuate a change and that institution-specific requirements may control with respect to that asset.

Confidentiality

The parties agree to maintain the confidentiality of beneficiary contact information and account specifics to the maximum extent permitted by law. Information required to be disclosed by a custodian, insurer, or by law shall not be considered a breach of this confidentiality provision.

Tax Indemnity

To the extent permitted by law and contract, beneficiaries receive assets subject to any taxes, penalties, or assessments applicable to the transfer. The Owner hereby directs that taxes and expenses associated with the transfer of designated assets be allocated as described in the Distribution Instructions above. Beneficiaries shall indemnify and hold harmless the custodian or payer for any tax withholding or reporting liability arising from distributions made pursuant to this designation.

Governing Law

This designation shall be governed by and construed in accordance with the laws of the State of , without regard to that State's conflict of laws rules.

Entire Agreement

This document sets forth the complete and exclusive designation of beneficiaries for the assets identified herein and supersedes any prior beneficiary designations for the same assets to the extent indicated. Any inconsistent term in a beneficiary designation form previously executed by the Owner is revoked as to assets listed above where this form expressly supersedes prior designations.

Owner Certification

I, the undersigned Owner, certify that I am of legal age and sound mind, that I have read and understand this Estate Beneficiary Designations form, and that the information and designations provided herein are true and made voluntarily. I understand that institution-specific requirements may also apply and that I may be required to complete additional forms with custodians or issuers to effect changes.

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