Beneficiary Information. While a designation of your beneficiary or beneficiaries is not required for investment, should you desire to identify your beneficiary of your investment herein, please provide the information requested below. If you live in a state with community property statutes and do not designate your spouse as the sole primary beneficiary, you represent and warrant that your spouse has consented to such a designation. Note that the information provided on this form will replace all existing primary and contingent beneficiary designations you have provided to us.
Beneficiary Information. Beneficiary information, which may or may not include individually-identifiable protected health information, will be managed in accordance with ACO’s HIPAA-compliant Privacy and Security Policy, ACO’s Data Use Policy, and the Business Associate and Qualified Service Organization Agreement, attached hereto as Exhibit B.
Beneficiary Information. I understand that unless I designate otherwise, my MNDCP beneficiary will be my surviving spouse, or if none, my estate. Beneficiary must be a natural person or qualifying trust. Beneficiaries will share equally if percentages are not provided. I may designate more than one person or entity (attach an additional sheet of paper if there is not enough space for your designating primary or contingent beneficiaries).
Beneficiary Information. When the Custodian receives proper instruction, you IRA assets will be distributed to the beneficiary you designate in this section. If the primary beneficiary does not survive you, your IRA assets will be distributed to the secondary beneficiary. In the event all beneficiaries are deceased, distribution is made to your estate. If you name more than one beneficiary in a class (primary or secondary), indicated percentage for each; the percentage must total 100%. All surviving beneficiaries within the class will share equally if you do not indicate percentages. To name a Trust as your beneficiary, attach a copy of the trust Agreement to this form. Enter the name, date and Social Security or Tax Identification Number of the trust and address of the Trustee below. If you need additional space to name beneficiaries, attach a separate sheet that includes all information requested below and indicates whether the beneficiaries are primary or secondary. Sign and date the sheet. You may change your beneficiaries at any time by sending written instructions to the Custodian.
Beneficiary Information. If a transfer request describes the intended beneficiary inconsistently by name and account number, then payment by the beneficiary’s Financial Institution might be made on the basis of the account number even if it identifies a person different from the named beneficiary. If the Customer is the originator of a transfer request containing an inconsistent name and account number, and the beneficiary’s Financial Institution, including Profinium, Inc., without knowledge of the inconsistency, makes payment on the basis of the account number, the Customer is obligated to pay the amount which is directed to the account number given.
Beneficiary Information. Account Holder (generally a parent or guardian). The Account Holder is typically the only person authorized to act on the Account. Name* Citizenship:* 🞏 U.S. Citizen 🞏 U.S. Resident Alien Social Security Number* Date of Birth (mm/dd/yyyy)* Residential Address (cannot be a P.O. box)* City* State* ZIP Code* Day Phone Evening Phone Email Address Mailing Address (if different from residential) City State ZIP Code An Account established with a trust, corporation, or other entity as the Account Holder requires the following: • For a trust, attach a copy of the trust agreement pages with the trust name and date, the trustee(s) name(s), and the signature page. • For a corporation or other entity, attach a copy of the corporate resolution, bylaws, charter, or other document that lists the person(s) authorized to act on behalf of the organization or other entity. Go Paperless. Going paperless means statements, confirmations, and Plan Disclosure Documents (when available) will be online for your convenience. 🞏 Check here, and we will send an email with details about completing the set up process online.
Beneficiary Information. Full Name: Address: Phone: Social Security Number (SSN): Birth date: Place of birth: Hospital: Mother's name: SSN: Father's name: SSN: □ legal guardian, □c onservator, □r If the Beneficiary has a legal representative (e.g., legal guardian, conservator, representative payee or agent under a power of attorney), please complete: Full Name: Address: Relationship: Source of legal authority: epresentative payee, □parent(s) □agent under a power of attorney, other: Date of appointment: What forms of government assistance does the Beneficiary receive? Check all that apply: Supplemental Security Income Medicare Social Security Disability Benefits Developmental Disability Waiver Medicaid-Medicaid #: Other: Is the Beneficiary covered under any policy of health insurance, if so please complete: Policy/Group # Insurer’s Name/Address: If the Beneficiary is covered under any prepaid funeral or burial insurance plan, please complete: Policy #: Insurer’s Name/Address: What is the nature of the Beneficiary's disability? What is the nature of the Beneficiary's medical diagnosis? What is the prognosis at this time?
Beneficiary Information o If you are requesting new products, you will need to complete and submit another Section C:
Beneficiary Information. Mr. Mrs. Ms. Address: City: State: Zip: Type of Residence: (e.g. private residence, group home) Home Phone: Cell Phone: Email Address:
Beneficiary Information. A copy of the Beneficiary’s Social Security Card is required. 11/2013
