Fill and Sign the Fsc Declared Form

BENEFICIARY DESIGNATION Plan Information Contract No: Cert No: Instructions for Completing This Form Please complete both sides of this enclosure if applicable. If the signature is missing from the backside of this form, this form is invalid. If mistakes are made, please cross a line through the item. Initial and date. If more space is required, please attach additional page(s) and designate beneficiaries as primary or contingent, as applicable. Please use complete legal names. Example: Mary J. Smith. Do not use Mrs. John H. Smith Participant Information – (Please Print) Full Name: (First) Date of Birth: (Middle) Soc. Sec. No.: (Date) (Last) E-mail Address: Ex. (999-99-9999) Designation of Primary Beneficiary(ies) – (Please Print) If more than one beneficiary is designated, please indicate the percentage (%) each beneficiary is to receive. The total percentage for all primary beneficiaries should equal 100%. If any primary beneficiary(ies) designated below predeceases the participant, the share which such beneficiary would have received, if such beneficiary had survived the participant, shall be payable equally to the remaining designated primary beneficiary or beneficiaries if any, who survive the participant, but if no primary beneficiary survives the participant, the benefits will be payable equally to any surviving contingent beneficiary(ies). If no contingent beneficiaries survive the participant, the remaining benefits will be payable to the participant's estate. Name: (First) (Middle) (Last) (Street) (City) (State) Address: Relationship: Date of Birth: Soc. Sec. No.: Share %: (ZIP) (Date) Ex. (999-99-9999) RPD864 Ex. (50%) Designation of Primary Beneficiary(ies) – (Please Print) (Continued) Name: (First) (Middle) (Last) (Street) (City) (State) Address: Relationship: Date of Birth: Soc. Sec. No.: Share %: (ZIP) (Date) Ex. (999-99-9999) Ex. (50%) Designation of Contingent Beneficiary(ies) – (Please Print) These designations only apply if all primary beneficiary(ies) predecease the participant. If more than one beneficiary is designated, please indicate the percentage (%) each contingent beneficiary is to receive. The total percentage for all contingent beneficiaries should equal 100%. If any contingent beneficiary designated below predeceases the participant, the share which such contingent beneficiary would have received, shall be payable equally to the remaining contingent beneficiary or beneficiaries. If no contingent beneficiaries survive the participant, the remaining benefits will be payable to the participant's estate. Name: (First) (Middle) (Last) (Street) (City) (State) Address: Relationship: Date of Birth: Soc. Sec. No.: Share %: (ZIP) (Date) Ex. (999-99-9999) Ex. (50%) Name: (First) (Middle) (Last) (Street) (City) (State) Address: Relationship: Date of Birth: Soc. Sec. No.: Share %: (ZIP) (Date) Ex. (999-99-9999) Ex. (50%) NOTE: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the Company. Penalties may include imprisonment, fines and denial of annuity benefits. I verify that the above information is complete and accurate. I understand that by making this beneficiary designation, I am revoking any and all prior beneficiary designations made by me. Signature Information – (Please Print and Sign) X Participant’s Name X Participant’s Signature (Date)