Legal Change of Beneficiary Form

LEGAL CHANGE OF BENEFICIARY FORM

Account Owner:   Account/Policy Number:   Institution Name:

RECITALS

WHEREAS, the Account Owner is the owner of the account, policy, or plan referenced above and has the authority to designate one or more beneficiaries with respect to death benefits and other payable interests arising under the account or plan; and

WHEREAS, the Account Owner previously designated one or more beneficiaries in connection with the account or plan and now desires to amend or replace those beneficiary designations as set forth in this Change of Beneficiary Form; and

WHEREAS, the Institution is authorized by its governing documents and applicable law to accept and record beneficiary designations submitted by the Account Owner and to rely on this Change of Beneficiary Form when processing benefits payable under the account or plan.

NOW, THEREFORE

In consideration of the foregoing recitals and the mutual covenants contained herein, the parties agree as follows:

1. CHANGE OF BENEFICIARY

The Account Owner hereby revokes and replaces any prior beneficiary designations for the account or policy identified above and designates the following person(s) and/or entity(ies) as beneficiaries effective on the Effective Date below. Proceeds shall be paid to beneficiaries surviving the Account Owner in the proportions set forth below unless otherwise required by law or the governing plan document.

Effective Date of Change

2. BENEFICIARY DESIGNATIONS

Primary Beneficiaries

Contingent Beneficiaries

If the designated beneficiaries do not survive the Account Owner, or if any beneficiary designation fails, the Institution shall distribute proceeds in accordance with the terms of the governing account or plan document and applicable law.

3. REVOCATION OF PRIOR DESIGNATIONS

By checking the box below and signing this form the Account Owner expressly revokes all prior beneficiary designations for the account or policy identified above, except to the extent explicitly preserved in writing herein.

I hereby revoke all prior beneficiary designations for the above account or policy.

4. REPRESENTATIONS AND WARRANTIES

The Account Owner represents and warrants that they have full legal capacity and authority to execute this Change of Beneficiary Form, that the information provided herein is true and complete to the best of their knowledge, and that the execution of this form does not violate any contract, court order, or other legal obligation binding the Account Owner.

5. PAYMENT TO MINOR OR INCOMPETENT BENEFICIARIES

If any beneficiary is a minor or legally incapacitated at the time of payment, the Institution may, in its discretion and to the extent permitted by law and its governing documents, pay benefits to the legal guardian, conservator, custodian under applicable transfer-on-death or custodial statutes, or into a blocked account or trust for the benefit of such beneficiary.

6. TAX, ESTATE AND OTHER CONSEQUENCES

The Account Owner acknowledges that the designation of a beneficiary may have federal, state or local tax consequences and may affect the Account Owner's estate plan. The Institution is not providing tax, estate planning or legal advice by accepting this Change of Beneficiary Form. The Account Owner is encouraged to consult their own tax or legal advisor regarding the consequences of this designation.

7. INSTITUTION ACKNOWLEDGMENT

By signing below, the Institution acknowledges receipt of this Change of Beneficiary Form and agrees to record the change in its records in accordance with its usual procedures, subject to verification of the Account Owner's authority and any requirements of the governing account or plan documents. The Institution's acknowledgment does not constitute an admission of liability or waiver of any rights under the account or plan.

8. NOTICE

Any notice required or permitted under this Change of Beneficiary Form shall be in writing and delivered to the addresses provided in this form or to such other address as a party designates by written notice. Notice is effective upon actual delivery or when sent by certified mail, return receipt requested.

9. MISCELLANEOUS

Entire Agreement: This Change of Beneficiary Form constitutes the entire agreement between the Account Owner and the Institution with respect to the subject matter herein and supersedes all prior communications and agreements regarding beneficiary designations, except as otherwise provided in the governing account or plan documents.

Governing Law: This Change of Beneficiary Form shall be governed by and construed in accordance with the substantive laws of the state in which the Institution maintains its principal place of business, without regard to conflict of laws principles.

Severability: If any provision of this Change of Beneficiary Form is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

Amendments and Waiver: No amendment or waiver of any provision of this Change of Beneficiary Form shall be effective unless in writing and signed by both the Account Owner and an authorized representative of the Institution. The failure of either party to enforce any provision shall not constitute a waiver of future enforcement of that or any other provision.

10. ADDITIONAL INFORMATION

Additional Instructions or Special Provisions

By signing below, the Account Owner certifies under penalty of perjury that the information provided in this Change of Beneficiary Form is true and correct, that they are the lawful owner of the account or have authority to direct beneficiary designations for the account or policy referenced above, and that they understand the effect of this designation.

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