OFFICER SALARY CONTINUATION AGREEMENT
Exhibit
10.15
THIS AGREEMENT, made and
entered into this 20th day of June, 2007, by and between Bank of Xxxxx, a bank
organized and existing under the laws of the State of Georgia (hereinafter
referred to as the “Bank”), and Xxxx X. Xxxxxxx, an Officer of the Bank
(hereinafter referred to as the “Officer”), a member of a select group of
management employees of the Bank.
WHEREAS, the Officer has been
and continues to be a valued Officer of the Bank;
WHEREAS, the purpose of this
Agreement is to further the growth and development of the Bank by providing the
Officer with supplemental retirement income, and thereby encourage the Officer’s
productive efforts on behalf of the Bank and the Bank’s shareholders, and to
align the interests of the Officer and those shareholders.
WHEREAS, it is the desire of
the Bank and the Officer to enter into this Agreement under which the Bank will
agree to make certain payments to the Officer at retirement or the Officer’s
Beneficiary in the event of the Officer’s death pursuant to this
Agreement;
ACCORDINGLY, it is intended
that the Agreement be “unfunded” for purposes of the Employee Retirement Income
Security Act of 1974, as amended (“ERISA”) and not be construed to provide
income to the participant or beneficiary under the Internal Revenue Code of
1986, as amended (the “Code”), particularly Section 409A of the Code and
guidance or regulations issued thereunder, prior to actual receipt of benefits;
and
THEREFORE, it is agreed as
follows:
I.
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EFFECTIVE
DATE
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The
Effective Date of this Agreement shall be March 29, 2006.
II.
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FRINGE
BENEFITS
|
The
salary continuation benefits provided by this Agreement are granted by the Bank
as a fringe benefit to the Officer and are not part of any salary reduction plan
or an arrangement deferring a bonus or a salary increase. The Officer
has no option to take any current payment or bonus in lieu of these salary
continuation benefits except as set forth hereinafter.
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III.
|
DEFINITIONS
|
|
A.
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Retirement
Date:
|
If the
Officer remains in the continuous employ of the Bank, the Officer shall retire
from active employment with the Bank on the later of the Officer’s sixty-fifth
(65th)
birthday or Separation from Service.
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B.
|
Normal Retirement
Age:
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“Normal
Retirement Age” shall mean the date on which the Officer attains age sixty-five
(65).
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C.
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Plan
Year:
|
Any
reference to “Plan Year” shall mean a calendar year from January 1st to
December 31st. In
the year of implementation, the term “Plan Year” shall mean the period from the
effective date to December 31st of the
year of the effective date.
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D.
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Termination of
Employment:
|
“Termination
of Employment” shall mean voluntary resignation of employment by the Officer or
the Bank’s discharge of the Officer without cause, prior to the Normal
Retirement Age.
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E.
|
Separation from
Service:
|
|
“Separation
from Service” shall mean that the Officer has experienced a Termination of
Employment from the Bank. Where the Officer continues to
perform services for the Bank following a Termination of Employment,
however, and the facts and circumstances indicate that such services are
intended by the Bank and the Officer to be more than “insignificant”
services, a Separation from Service will not be deemed to have occurred
and any amounts deferred under this Agreement may not be paid or made
available to the Officer. The determination of whether such
services are considered “insignificant” will be based upon all facts and
circumstances relating to the termination and upon any applicable rules
and regulations issued under Section 409A of the Code. Military
leave, sick leave, or other bona fide leaves of absence are not generally
considered terminations of
employment.
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|
F.
|
Discharge for
Cause:
|
The term
“for cause” shall mean any of the following that result in an adverse effect on
the Bank: (i) the commission of a felony or gross misdemeanor involving fraud or
dishonesty; (ii) the willful violation of any banking law,
rule,
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or
banking regulation (other than a traffic violation or similar offense); (iii) an
intentional failure to perform stated duties; or (iv) a breach of fiduciary duty
involving personal profit. If a dispute arises as to discharge “for
cause,” such dispute shall be resolved by arbitration as set forth in this
Agreement. In the alternative, if the Officer is permitted to resign
due to inappropriate conduct as defined above, the Board of Directors may vote
to deny all benefits. A majority decision by the Board of Directors
is required for forfeiture of the Officer’s benefits.
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G.
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Change of
Control:
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“Change
of Control” shall mean a change in ownership or control of the Bank as defined
in Treasury Regulation Section 1.409A-3(g)(5) or any subsequently applicable
Treasury Regulation.
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H.
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Restriction on Timing
of Distribution:
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Notwithstanding
any provision of this Agreement to the contrary, distributions to the Officer
may not commence earlier than six (6) months after the date of a Separation from
Service, as that term is used under Section 409A if, pursuant to Internal
Revenue Code Section 409A, the Officer is considered a “specified employee”
under Internal Revenue Code Section 416(i), of the Bank if any stock of the Bank
is publicly traded on an established securities market or
otherwise. In the event a distribution is delayed pursuant to this
paragraph, the originally scheduled payment shall be delayed for six (6) months,
and shall commence instead on the first day of the seventh month following
Separation from Service. If payments are scheduled to be made in
installments, the first six (6) months of installment payments shall be delayed,
aggregated, and paid instead on the first day of the seventh month, after which
all installment payments shall be made on their regular schedule. If
payment is scheduled to be made in a lump sum, the lump payment shall be delayed
for six (6) months and instead be made on the first day of the seventh
month.
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I.
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Beneficiary:
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The
Officer shall have the right to name a Beneficiary of the death benefit as
described in Paragraph IV herein. The Officer shall have the right to
name such Beneficiary at any time prior to the Officer’s death and submit it to
the Plan Administrator (or Plan Administrator’s representative) on the form
provided. Once received and acknowledged by the Plan Administrator,
the form shall be effective. The Officer may change a Beneficiary
designation at any time by submitting a new form to the Plan
Administrator. Any such change shall follow the same rules as for the
original Beneficiary designation and shall automatically supersede the existing
Beneficiary form on file with the Plan Administrator.
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If the
Officer dies without a valid Beneficiary designation on file with the Plan
Administrator, death benefits shall be paid to the Officer’s
estate.
If the
Plan Administrator determines in its discretion that a benefit is to be paid to
a minor, to a person declared incompetent, or to a person incapable of handling
the disposition of that person’s property, the Plan Administrator may direct
distribution of such benefit to the guardian, legal representative or person
having the care or custody of such minor, incompetent person or incapable
person. The Plan Administrator may require proof of incompetence,
minority or guardianship as it may deem appropriate prior to distribution of the
benefit. Any distribution of a benefit shall be a distribution for
the account of the Officer and the Beneficiary, as the case may be, and shall be
a complete discharge of any liability under the Agreement for such distribution
amount.
IV.
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RETIREMENT
BENEFIT
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Upon
attainment of the Retirement Date, the Bank shall pay the Officer an annual
benefit equal to Twenty-Five Thousand and 00.100th Dollars
($25,000.00). Said benefit shall be paid in equal monthly
installments (1/12th of the
annual benefit) until the death of the Officer. Said payment shall be
made the first day of the month following the date of such Separation from
Service.
V.
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DEATH
BENEFIT
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A.
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Pre-Retirement Death
Benefit:
|
In the
event the Officer should die while actively employed by the Bank at any time
after the date of this Agreement but prior to the Officer attaining the
Retirement Date, the Bank will pay the accrued balance on the date of death, of
the Officer’s accrued liability retirement account in one (1) lump sum, the
first day of the second month following the Officer’s death, to the
Beneficiary.
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B.
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Post-Retirement Death
Benefit:
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Upon the
death of the Officer, if there is a balance in the accrued liability retirement
account, such balance shall be paid in one (1) lump sum to the
Beneficiary. Said payment due hereunder shall be made the first day
of the second month following the Officer’s death.
VI.
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ACCRUED
LIABILITY RETIREMENT ACCOUNT
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The Bank
shall account for this benefit using the regulatory accounting principles of the
Bank’s primary federal regulator. The Bank shall establish an accrued
liability retirement account for the Officer into which appropriate reserves
shall be accrued.
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VII.
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VESTING
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The
Officer shall be vested in the accrued liability retirement account in
accordance with the following schedule to a maximum of one hundred percent
(100%).
Age of
Officer
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Vested (to a maximum
of 100%)
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Age
59 and under
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0%
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60
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50%
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61
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60%
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62
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70%
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63
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80%
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64
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90%
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65
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100%
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VIII.
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TERMINATION
OF EMPLOYMENT
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In the
event that the employment of the Officer shall terminate prior to Normal
Retirement Age, by the Officer’s voluntary action, or by the Officer’s discharge
by the Bank without cause, then this Agreement shall terminate upon the date of
such termination of employment and the Bank shall pay to the Officer an amount
of money equal to balance of the Officer’s accrued liability retirement account
on the date of said termination, multiplied by the Officer’s cumulative vested
percentage. This compensation shall be paid in one (1) lump sum the
first day of the second month following Separation from Service.
In the
event the Officer’s death should occur after such termination but prior to the
payment provided for in this paragraph, the balance shall be paid, in one (1)
lump sum to the Beneficiary. Said payment due hereunder shall be made
the first day of the second month following the decease of the
Officer.
In the
event the Officer shall be discharged for cause at any time, this Agreement
shall terminate and all benefits provided herein shall be
forfeited.
IX.
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CHANGE
OF CONTROL
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If the
Officer subsequently suffers a Termination of Employment (voluntarily or
involuntarily), except for cause, anytime subsequent to a Change of Control,
then the Officer shall receive the benefits stated in Paragraph IV herein upon
attaining Normal Retirement Age, as if the Officer had been continuously
employed by the Bank until the Officer’s Normal Retirement Age.
X.
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RESTRICTIONS
ON FUNDING
|
The Bank
shall have no obligation to set aside, earmark or entrust any fund or money with
which to pay its obligations under this Agreement. The Officer, their
beneficiary(ies), or any successor in interest shall be and remain simply a
general creditor
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of the
Bank in the same manner as any other creditor having a general claim for matured
and unpaid compensation.
The Bank
reserves the absolute right, at its sole discretion, to either fund the
obligations undertaken by this Agreement or to refrain from funding the same and
to determine the extent, nature and method of such funding. Should
the Bank elect to fund this Agreement, in whole or in part, through the purchase
of life insurance, mutual funds, disability policies or annuities, the Bank
reserves the absolute right, in its sole discretion, to terminate such funding
at any time, in whole or in part. At no time shall any Officer be
deemed to have any lien, right, title or interest in any specific funding
investment or assets of the Bank.
If the
Bank elects to invest in a life insurance, disability or annuity policy on the
life of the Officer, then the Officer shall assist the Bank by freely submitting
to a physical exam and supplying such additional information necessary to obtain
such insurance or annuities.
XI.
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MISCELLANEOUS
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A.
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Alienability and
Assignment Prohibition:
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Neither
the Officer, nor the Officer’s surviving spouse, nor any other Beneficiary under
this Agreement shall have any power or right to transfer, assign, anticipate,
hypothecate, mortgage, commute, modify or otherwise encumber in advance any of
the benefits payable hereunder nor shall any of said benefits be subject to
seizure for the payment of any debts, judgments, alimony or separate maintenance
owed by the Officer or the Officer’s Beneficiary, nor be transferable by
operation of law in the event of bankruptcy, insolvency or
otherwise. In the event the Officer or any Beneficiary attempts
assignment, commutation, hypothecation, transfer or disposal of the benefits
hereunder, the Bank’s liabilities shall forthwith cease and
terminate.
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B.
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Binding Obligation of
the Bank and any Successor in
Interest:
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The Bank
shall not merge or consolidate into or with another bank or sell substantially
all of its assets to another bank, firm or person until such bank, firm or
person expressly agree, in writing, to assume and discharge the duties and
obligations of the Bank under this Agreement. This Agreement shall be
binding upon the parties hereto, their successors, beneficiaries, heirs and
personal representatives.
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C.
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Amendment or
Revocation:
|
Subject
to Paragraph XIII, it is agreed by and between the parties hereto that, during
the lifetime of the Officer, this Agreement may be amended or revoked at any
time or times, in whole or in part, by the mutual written consent of the Officer
and the Bank. Any such amendment shall not be effective to decrease
or restrict
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any
Officer’s accrued benefit under this Agreement, determined as of the date of
amendment, unless agreed to in writing by the Officer, and provided further, no
amendment shall be made, or if made, shall be effective, if such amendment would
cause the Agreement to violate Internal Revenue Code Section 409A. In
the event this Agreement is terminated, such termination shall not cause a
distribution of benefits, except under limited circumstances as permitted under
Section 409A (i.e., 30 days before or 12 months after a Change of Control event,
upon termination of all arrangements of the same type, or upon corporate
dissolution or bankruptcy).
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D.
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Gender:
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Whenever
in this Agreement words are used in the masculine or neutral gender, they shall
be read and construed as in the masculine, feminine or neutral gender, whenever
they should so apply.
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E.
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Headings:
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Headings
and subheadings in this Agreement are inserted for reference and convenience
only and shall not be deemed a part of this Agreement.
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F.
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Applicable
Law:
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The laws
of the State of Georgia shall govern the validity and interpretation of this
Agreement.
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G.
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Partial
Invalidity:
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If any
term, provision, covenant, or condition of this Agreement is determined by an
arbitrator or a court, as the case may be, to be invalid, void, or
unenforceable, such determination shall not render any other term, provision,
covenant, or condition invalid, void, or unenforceable, and the Agreement shall
remain in full force and effect notwithstanding such partial
invalidity.
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H.
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Not a Contract of
Employment:
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This
Agreement shall not be deemed to constitute a contract of employment between the
parties hereto, nor shall any provision hereof restrict the right of the Bank to
discharge the Officer, or restrict the right of the Officer to terminate
employment.
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I.
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Tax
Withholding:
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The Bank
shall withhold any taxes that are required to be withheld, under Section 409A of
the Code and regulations thereunder, from the benefits provided under this
Agreement. The Officer acknowledges that the Bank’s sole
liability
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regarding
taxes is to forward any amounts withheld to the appropriate taxing
authority(ies).
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J.
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Opportunity to Consult
with Independent Advisors:
|
The
Officer acknowledges that he has been afforded the opportunity to consult with
independent advisors of his choosing including, without limitation, accountants
or tax advisors and counsel regarding both the benefits granted to him under the
terms of this Agreement and the: (i) terms and conditions which may affect the
Officer’s right to these benefits; and (ii) personal tax effects of such
benefits including, without limitation, the effects of any federal or state
taxes, Section 280G of the Code, Section 409A of the Code and guidance or
regulations thereunder, and any other taxes, costs, expenses or liabilities
whatsoever related to such benefits, which in any of the foregoing instances the
Officer acknowledges and agrees shall be the sole responsibility of the Officer
notwithstanding any other term or provision of this Agreement. The
Officer further acknowledges and agrees that the Bank shall have no liability
whatsoever related to any such personal tax effects or other personal costs,
expenses, or liabilities applicable to the Officer and further specifically
waives any right for himself or herself, and his or her heirs, beneficiaries,
legal representative, agents, successor and assign to claim or assert liability
on the part of the Bank related to the matters described above in this
paragraph. The Officer further acknowledges that he has read,
understands and consents to all of the terms and conditions of this Agreement,
and that he enters into this Agreement with a full understanding of its terms
and conditions.
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K.
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Permissible
Acceleration Provision:
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Under
Section 409A(a)(3), a payment of deferred compensation may not be accelerated
except as provided in regulations by the Internal Revenue
Code. Certain permissible payment accelerations include payments
necessary to comply with a domestic relations order, payments necessary to
comply with certain conflict of interest rules, payments intended to pay
employment taxes, and certain de minimis payments related to the participant’s
termination of the Officer’s interest in the plan.
XII.
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ADMINISTRATIVE
AND CLAIMS PROVISION
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A.
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Plan
Administrator:
|
The “Plan
Administrator” of this Agreement shall be Bank of Xxxxx. As Plan
Administrator, the Bank shall be responsible for the management, control and
administration of the Agreement. The Plan Administrator may delegate
to others certain aspects of the management and operation responsibilities of
the Agreement including the employment of advisors and the delegation of
ministerial duties to qualified individuals.
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B.
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Claims
Procedure:
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a.
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Filing a Claim for
Benefits:
|
Any
insured, Beneficiary, or other individual, (“Claimant”) entitled to benefits
under this Agreement will file a claim request with the Plan
Administrator. The Plan Administrator will, upon written request of a
Claimant, make available copies of all forms and instructions necessary to file
a claim for benefits or advise the Claimant where such forms and instructions
may be obtained. If the claim relates to disability benefits, then
the Plan Administrator shall designate a sub-committee to conduct the initial
review of the claim (and applicable references below to the Plan Administrator
shall mean such sub-committee).
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b.
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Denial of
Claim:
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A claim
for benefits under this Agreement will be denied if the Bank determines that the
Claimant is not entitled to receive benefits under the Agreement. Notice of a
denial shall be furnished the Claimant within a reasonable period of time after
receipt of the claim for benefits by the Plan Administrator. This
time period shall not exceed more than ninety (90) days after the receipt of the
properly submitted claim. In the event that the claim for benefits
pertains to disability, the Plan Administrator shall provide written notice
within forty-five (45) days. However, if the Plan Administrator
determines, in its discretion, that an extension of time for processing the
claim is required, such extension shall not exceed an additional ninety (90)
days. In the case of a claim for disability benefits, the forty-five
(45) day review period may be extended for up to thirty (30) days if necessary
due to circumstances beyond the Plan Administrator’s control, and for an
additional thirty (30) days, if necessary. Any extension notice shall
indicate the special circumstances requiring an extension of time and the date
by which the Plan Administrator expects to render the determination on
review.
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c.
|
Content of
Notice:
|
The Plan
Administrator shall provide written notice to every Claimant who is denied a
claim for benefits which notice shall set forth the following:
|
(i.)
|
The
specific reason or reasons for the
denial;
|
|
(ii.)
|
Specific
reference to pertinent Agreement provisions on which the denial is
based;
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(iii.)
|
A
description of any additional material or information necessary for the
Claimant to perfect the claim, and any explanation of why such material or
information is necessary; and
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(iv.)
|
Any
other information required by applicable regulations, including with
respect to disability benefits.
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d.
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Review
Procedure:
|
The
purpose of the Review Procedure is to provide a method by which a Claimant may
have a reasonable opportunity to appeal a denial of a claim to the Plan
Administrator for a full and fair review. The Claimant, or his duly
authorized representative, may:
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(i.)
|
Request
a review upon written application to the Plan Administrator. Application
for review must be made within sixty (60) days of receipt of written
notice of denial of claim. If the denial of claim pertains to
disability, application for review must be made within one hundred eighty
(180) days of receipt of written notice of the denial of
claim;
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(ii.)
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Review
and copy (free of charge) pertinent Agreement documents, records and other
information relevant to the Claimant’s claim for
benefits;
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(iii.)
|
Submit
issues and concerns in writing, as well as documents, records, and other
information relating to the claim.
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|
e.
|
Decision on
Review:
|
A
decision on review of a denied claim shall be made in the following
manner:
|
(i.)
|
The
Plan Administrator may, in its sole discretion, hold a hearing on the
denied claim. If the Claimant’s initial claim is for disability benefits,
any review of a denied claim shall be made by members of the Plan
Administrator other than the original decision maker(s) and such person(s)
shall not be a subordinate of the original decision
maker(s). The decision on review shall be made promptly, but
generally not later than sixty (60) days after receipt of the application
for review. In the event that the denied claim pertains to
disability, such decision shall not be made later than forty-five (45)
days after receipt of the application for review. If the Plan
Administrator determines that an extension of time for processing is
required, written notice of the extension shall be furnished to the
Claimant prior to the termination of the
initial
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sixty
(60) day period. In no event shall the extension exceed a period of
sixty (60) days from the end of the initial period. In the event the
denied claim pertains to disability, written notice of such extension shall be
furnished to the Claimant prior to the termination of the initial forty-five
(45) day period. In no event shall the extension exceed a period of
thirty (30) days from the end of the initial period. The extension
notice shall indicate the special circumstances requiring an extension of time
and the date by which the Plan Administrator expects to render the determination
on review.
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(ii.)
|
The
decision on review shall be in writing and shall include specific reasons
for the decision written in an understandable manner with specific
references to the pertinent Agreement provisions upon which the decision
is based.
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(iii.)
|
The
review will take into account all comments, documents, records and other
information submitted by the Claimant relating to the claim without regard
to whether such information was submitted or considered in the initial
benefit determination. Additional considerations shall be
required in the case of a claim for disability benefits. For
example, the claim will be reviewed without deference to the initial
adverse benefits determination and, if the initial adverse benefit
determination was based in whole or in part on a medical judgment, the
Plan Administrator will consult with a health care professional with
appropriate training and experience in the field of medicine involving the
medical judgment. The health care professional who is consulted
on appeal will not be the same individual who was consulted during the
initial determination or the subordinate of such individual. If
the Plan Administrator obtained the advice of medical or vocational
experts in making the initial adverse benefits determination (regardless
of whether the advice was relied upon), the Plan Administrator will
identify such experts.
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(iv.)
|
The
decision on review will include a statement that the Claimant is entitled
to receive, upon request and free of charge, reasonable access to, and
copies of, all documents, records or other information relevant to the
Claimant’s claim for benefits.
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f.
|
Exhaustion of
Remedies:
|
A
Claimant must follow the claims review procedures under this Agreement and
exhaust his or her administrative remedies before taking any further action with
respect to a claim for benefits.
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C.
|
Arbitration:
|
If
claimants continue to dispute the benefit denial based upon completed
performance of this Agreement or the meaning and effect of the terms and
conditions thereof, then claimants may submit the dispute to an Arbitrator for
final arbitration. The Arbitrator shall be selected by mutual
agreement of the Bank and the claimants. The Arbitrator shall operate
under any generally recognized set of arbitration rules. The parties
hereto agree that they and their heirs, personal representatives, successors and
assigns shall be bound by the decision of such Arbitrator with respect to any
controversy properly submitted to it for determination.
Where a
dispute arises as to the Bank’s discharge of the Officer “for cause,” such
dispute shall likewise be submitted to arbitration as above described and the
parties hereto agree to be bound by the decision thereunder.
XIII.
|
TERMINATION
OR MODIFICATION OF AGREEMENT BY REASON OF CHANGES IN THE LAW, RULES OR
REGULATIONS
|
The Bank
is entering into this Agreement upon the assumption that certain existing tax
laws, rules and regulations will continue in effect in their current
form. If any said assumptions should change and said change has a
detrimental effect on this Agreement, then the Bank reserves the right to
terminate or modify this Agreement accordingly. Any such termination
or modification shall not be effective to decrease or restrict any Officer’s
Accrued Liability Retirement Account under this Agreement, determined as of the
date of amendment, unless agreed to in writing by the Officer, and provided
further, no amendment shall be made, or if made, shall be effective, if such
termination or modification would cause the Agreement to violate Internal
Revenue Code Section 409A. In the event this Agreement is
terminated, such termination shall not cause a distribution of benefits, except
under limited circumstances as permitted under Section 409A (i.e., 30 days
before or 12 months after a Change in Control event, upon termination of all
arrangements of the same type, or upon corporate dissolution or
bankruptcy). Upon a Change of Control, this paragraph shall become
null and void effective immediately upon said Change of
Control.
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IN WITNESS WHEREOF, the
parties hereto acknowledge that each has carefully read this Agreement and
executed the original thereof on the first day set forth hereinabove, and that,
upon execution, each has received a conforming copy.
BANK
OF XXXXX
|
||||
Thomaston,
Georgia
|
||||
By:
|
||||
Witness
|
(Bank Officer other than
Insured)
|
Title
|
||
Witness
|
Xxxx
X. Xxxxxxx
|
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BENEFICIARY
DESIGNATION FORM FOR THE OFFICER SALARY CONTINUATION AGREEMENT
I.
|
PRIMARY
DESIGNATIONS
|
|||||||
A.
|
Person(s)
as a Primary Designation:
(Please
indicate the percentage for each beneficiary.)
|
|||||||
1.
|
Name:
|
Relationship:
|
SS#:
|
%
|
||||
(Street)
|
(City)
|
(State)
|
(Zip)
|
|||||
2.
|
Name:
|
Relationship:
|
SS#:
|
%
|
||||
(Street)
|
(City)
|
(State)
|
(Zip)
|
|||||
3.
|
Name:
|
Relationship:
|
SS#:
|
%
|
||||
(Street)
|
(City)
|
(State)
|
(Zip)
|
|||||
4.
|
Name:
|
Relationship:
|
SS#:
|
%
|
||||
(Street)
|
(City)
|
(State)
|
(Zip)
|
II.
|
ESTATE AND/OR TRUST AS
PRIMARY DESIGNATIONS
|
|||||||||
A.
|
Estate as a Primary
Designation:
An
Estate can still be listed even if there is no will.
|
|||||||||
My
Primary Beneficiary is The Estate of
|
as
set forth in the Last Will and
|
|||||||||
(Insert
full name)
|
||||||||||
Testament
dated the
|
day of
|
,
200
|
and
any codicils thereto.
|
|||||||
B.
|
Trust as a Primary
Designation:
|
|||||||||
Name
of the Trust:
|
||||||||||
Execution
Date of the Trust:
|
Name
of the Trustee:
|
|||||||||
Beneficiary
of the Trust:
(please
indicate the percentage for each beneficiary):
|
||||||||||
Name(s):
|
||||||||||
Name(s):
|
||||||||||
Is this an Irrevocable Life
Insurance Trust? □
Yes
□ No
|
||||||||||
(If
yes and this designation is for a Joint Beneficiary Designation Agreement,
an Assignment of Rights form must
be completed.)
|
- 14
-
III.
|
SECONDARY (CONTINGENT)
DESIGNATIONS
|
|||||||
A.
|
Person(s)
as a Secondary (Contingent) Designation:
(Please
indicate the percentage for each beneficiary in the event of the Primary’s
Death.)
|
|||||||
1.
|
Name:
|
Relationship:
|
SS#:
|
%
|
||||
(Street)
|
(City)
|
(State)
|
(Zip)
|
|||||
2.
|
Name:
|
Relationship:
|
SS#:
|
%
|
||||
(Street)
|
(City)
|
(State)
|
(Zip)
|
|||||
3.
|
Name:
|
Relationship:
|
SS#:
|
%
|
||||
(Street)
|
(City)
|
(State)
|
(Zip)
|
|||||
4.
|
Name:
|
Relationship:
|
SS#:
|
%
|
||||
(Street)
|
(City)
|
(State)
|
(Zip)
|
IV.
|
ESTATE AND/OR TRUST AS
SECONDARY (CONTINGENT) DESIGNATIONS
|
|||||||||
A.
|
Estate as a Secondary
(Contingent) Designation:
|
|||||||||
My
Primary Beneficiary is The Estate of
|
as
set forth in the last will and
|
|||||||||
Testament
dated the
|
day of
|
,
200
|
and
any codicils thereto.
|
|||||||
B.
|
Trust as a Secondary
(Contingent) Designation:
|
|||||||||
Name
of the Trust:
|
||||||||||
Execution
Date of the Trust:
|
Name
of the Trustee:
|
|||||||||
Beneficiary
of the Trust:
(please
indicate the percentage for each beneficiary):
|
||||||||||
Name(s):
|
||||||||||
Name(s):
|
||||||||||
Is this an Irrevocable Life
Insurance Trust? □
Yes □
No
|
||||||||||
(If
yes and this designation is for a Joint Beneficiary Designation Agreement,
an Assignment of Rights form must
be completed.)
|
||||||||||
V.
|
SIGN AND
DATE
|
|||||||||
This
Beneficiary Designation Form is valid until the participant notifies the
bank in writing.
|
Xxxx
X. Xxxxxxx
|
Date
|
- 15
-