Fill and Sign the Georgia Assignment of Contract for Deed by Seller Form

Designation or Change of Beneficiary Request State Farm Mutual Funds® Individual Retirement Accounts, Tax Sheltered Accounts (TSA) under 403(b)(7), or Archer Medical Savings Accounts (MSA). This form is used to designate or change the Beneficiary(ies) of your Traditional IRA, Roth IRA, SEP IRA, SIMPLE IRA, TSA, or MSA. If you wish to establish a transfer on death beneficiary on your non-tax qualified State Farm Mutual Fund account, please call and request a Designation or Change of Transfer on Death (TOD) Beneficiary Form. By completing this form you revoke any prior death beneficiary designation and name the following as the beneficiary(ies) of this account, subject to your right to change this designation as provided in the applicable Custodial Account Agreement. If you have any questions or need additional information before completing this form, please call 1-800-447-4930. 1 Instructions 1. This form is deemed valid by the Custodian if the following requirements have been met: a) The beneficiary information is complete. b) It is signed and dated by the Participant. c) Your spouse has signed the form - if required. d) It is filed with the Custodian prior to your death. 2. To name more than four primary or secondary beneficiaries: a) Attach a separate page and include, for each beneficiary, all of the information requested on this form. Have your spouse sign the page, if required. b) Sign and date the additional page. c) Have your spouse sign the page, if required. 3. See the applicable State Farm Mutual Funds Custodial Account Agreements for additional provisions. 2 Participant Information First Name MI Last Name Address Social Security Number City State Account Number ZIP Code Marital Status Telephone Number Single Married 3 Designation of Beneficiary All fields must be completed for each beneficiary. Name SSN/TIN (PRIMARY BENEFICIARY(IES) Street Name SSN/TIN Street Relationship Relationship City Date of Birth (Month/Day/Year) Date of Birth (Month/Day/Year) State City SSN/TIN (Month/Day/Year) State City Street Name Relationship SSN/TIN Date of Birth State City Street Name Relationship Date of Birth (Month/Day/Year) State % of Account ZIP Code % of Account ZIP Code % of Account ZIP Code % of Account ZIP Code Total = 100% 1004549 104203.4 05-15-2012 (SECONDARY BENEFICIARY(IES) Name SSN/TIN Street Name SSN/TIN Street Relationship Date of Birth (Month/Day/Year) Date of Birth (Month/Day/Year) State City SSN/TIN (Month/Day/Year) State City Street Name Relationship SSN/TIN Date of Birth State City Street Name Relationship Relationship City Date of Birth (Month/Day/Year) State % of Account ZIP Code % of Account ZIP Code % of Account ZIP Code % of Account ZIP Code Total = 100% 4 Signature(s) Participant's Signature Date Signature of Spouse (if required*) *Note: Spouse's signature is required if the spouse is not the sole primary beneficiary for this account and the spouse and/or Participant resides in Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington or Wisconsin. By signing, spouse voluntarily and irrevocably consents to the beneficiary designation set forth above and waives all rights he/she may have with respect to the account, except for any rights provided under the applicable Custodial Account Agreement. Please fax or mail all signed completed forms to: State Farm Mutual Funds P.O. Box 219548 Kansas City, Missouri 64121-9548 FAX: 1-816-471-4832 1004549 104203.4 05-15-2012