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Beneficiary Designation Form Sample

This sample is provided for general information purposes. Deferral.com does not practice law or render legal, tax or investment advice. No plan should be adopted without review and advice of legal counsel and other professional advisers familiar with the employer's business, facts and circumstances, as affected by Section 409A of the Internal Revenue Code and other applicable law.



TO: ABC Corporation, Inc., (hereinafter referred to as the "Company") I, _________________________, in accordance with the rights granted to me in the Deferred Compensation Plan Agreement, between me and the Company, do hereby nominate as Beneficiary thereunder to receive payments thereunder in the event of my death:

Beneficiary Designations
Primary Beneficiary(ies) Relationship Percent Date
of Birth



Contingent Beneficiary(ies) Relationship Percent Date
of Birth



I further reserve the privilege of changing the Beneficiary herein named at any time or times without the consent of any such beneficiary. This nomination is made upon the following terms and conditions:

  1. The word Beneficiary as used herein shall include the plural, Beneficiaries, wherever the Agreement permits.

  2. For purposes of this Beneficiary Designation, no person shall be deemed to have survived the participant if that person dies within thirty (30) days of the participant's death.

  3. Beneficiary shall mean the Primary Beneficiary if such Primary Beneficiary survives the participant by at least thirty (30) days, and shall mean the 1st Contingent Beneficiary if the Primary Beneficiary does not survive the participant by at least thirty (30) days.

  4. If the Primary Beneficiary shall be deceased on any annual payment date provided in said Agreement, any and all remaining annual payments shall be payable to the 1st Contingent Beneficiary unless the executors or administrators of said deceased Beneficiary are named as Primary Beneficiary herein above.

  5. If more than one Beneficiary is named within the same class (i.e., Primary or 1st Contingent), then annual payments shall be made equally to such Beneficiaries unless otherwise provided herein above. If any such Beneficiary dies while receiving annual payments under said Agreement, any and all remaining payments shall continue to be made to the surviving Beneficiaries of such class and to the legal heirs of the deceased Beneficiary, which legal heirs shall receive the amount which was being received by said deceased Beneficiary. If all of the Beneficiaries of a class shall die, any and all remaining payments shall be made to the next class of Beneficiaries, as provided under Paragraph 4 above.

  6. If none of the Beneficiaries named herein above are living on any said annual payment date, any and all remaining payments shall be made to my executors or administrators, or upon their written request, to any person or persons so designated by them.

  7. If any such annual payments shall be payable to any trust, the Corporation shall not be liable to see to the application by the Trustee of any payment hereunder at any time, and may rely upon the sole signature of the Trustee to any receipt, release or waiver, or to any transfer or other instrument to whomsoever made purporting to affect this nomination or any right hereunder.

This nomination cancels and supersedes any Nomination of Beneficiary heretofore made by me with respect to said Agreement and the right to receive payments thereunder.

Dated: __________________________
Received this ________ day of _________________, 200___

(Participant's Signature)

Spouse's Consent (to be completed if Participant's Spouse is not 100% Primary Beneficiary):

I hereby consent to the beneficiary designation made on this Beneficiary Designation Form. I understand that:

  1. I would receive 100% of the amount payable under the Plan on account of my spouse's death if I do not consent to the Primary Beneficiary Designation made above.

  2. The beneficiary(ies) will be entitled to my spouse's account balance upon his or her death.

  3. My spouse's election cannot be effective without my consent.

  4. My consent is irrevocable unless my spouse revokes his or her beneficiary designation.

Printed Name of Participant's Spouse

____________________________________________________   ____________________
Spouse's Signature                                                                                       Date Signed

Printed Name of Notary Public or Authorized Plan Representative

____________________________________________________   ___________________
Signature of Notary Public or Authorized Plan Representative               Date Signed

My Notary Commission Expires: ____________, 20___


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