EXHIBIT 10 (c)
XXXXXX XXXXXXX DEFERRED COMPENSATION PLAN AGREEMENT
THIS AGREEMENT, made and entered into this _____ day of
______________, 1995, by and between BLUE BALL NATIONAL BANK, a
national banking association with principal offices and place of
business at 0000 Xxxx Xxxxxx, Post Xxxxxx Xxx 000, Xxxx Xxxx,
Xxxxxxxxxxxx, 00000 (hereinafter referred to as the "Bank"), and
XXXXXX XXXXXXX, an adult individual residing at 00 Xxxxxxx
Xxxxxx, Xxx Xxxxxxx, Xxxxxxxxxxxx (hereinafter referred to as
"Xxxxxxx"),
WITNESSETH:
WHEREAS, Xxxxxxx is employed by the Bank; and
WHEREAS, the Bank recognizes the valuable services
heretofore performed for it by Xxxxxxx and wishes to encourage
his continued employment; and
WHEREAS, Xxxxxxx wishes to defer a certain portion of
compensation payable to him; and
WHEREAS, the parties hereto wish to provide the terms and
conditions upon which the Bank shall pay such deferred
compensation to Xxxxxxx or his designated beneficiary; and
WHEREAS, the parties intend that this Agreement be
considered an unfunded arrangement, maintained primarily to
provide deferred compensation benefits for Xxxxxxx, a member of
select group of management or highly compensated employees of the
Bank, for purposes of Employee Retirement Income Act of 1974, as
amended;
NOW, THEREFORE, in consideration of the premises and of the
mutual promises herein contained, the parties hereto agree as
follows:
1. DEFINITION OF TERMS. Certain words and phrases are
defined when first used in this Agreement. In addition, the
following words and phrases when used herein, unless the context
clearly requires otherwise, shall have the following respective
meanings:
(a) Accrued Benefit. The sum of all Deferred Amounts
credited to Xxxxxxx'x Retirement Account and due and owing
to Xxxxxxx or his beneficiaries pursuant to this Agreement,
together with Additions thereto calculated as set forth in
paragraph 3 hereof, minus any distributions hereunder.
(b) Affiliate. Any corporation, partnership, joint
venture, association, or similar organization or entity, the
employees of which would be treated as employed by the Bank
under Section 414(b) and 414(c) of the Code.
(c) Agreement. This Agreement, together with any and
all amendments or supplements thereto.
(d) Code. The Internal Revenue Code of 1986, 26
U.S.C. 101 et seq., as amended or as it may be amended from
time to time.
(e) Compensation. Total salary and commissions of
Xxxxxxx paid or accrued by the Bank, exclusive of Accrued
Benefits, stock options, stock appreciation rights, and any
employer contributions or payments to any other trust, fund,
agreement or plan providing retirement, pension, profit
sharing, health, welfare, death, insurance or similar
benefits.
(f) Deferred Amount. A portion of the Compensation
otherwise payable to Xxxxxxx, receipt of which Xxxxxxx has
elected to defer under the provisions of paragraphs 2 and 4
hereof.
(g) Effective Date. The date of the execution of this
Agreement.
(h) Election of Deferral. A written notice filed by
Xxxxxxx with the Payroll Department of the Bank in
substantially the form attached hereto as Exhibit "A,"
specifying the amount of Compensation to be deferred.
(i) Fiscal Year. The taxable year of the Bank.
(j) Normal Retirement Date. The date Xxxxxxx attains
sixty-five (65) years of age.
(k) Notice of Discontinuance. A written notice filed
by Xxxxxxx with the Payroll Department of the Bank in
substantially the form attached hereto as Exhibit "B,"
requesting discontinuance of the deferral of Xxxxxxx'x
Compensation.
(l) Retirement Account. Book entries maintained by
the Bank reflecting Deferred Amounts and Additions thereon;
provided, however, that the existence of such book entries
and the Retirement Account shall not create and shall not be
deemed to create a trust of any kind, or a fiduciary
relationship between the Bank and Xxxxxxx, his designated
beneficiary, or other beneficiaries under this Agreement.
2. DEFERRED COMPENSATION. Commencing on the Effective
Date, and continuing through the date on which Xxxxxxx'x
employment terminates because of his death, normal retirement,
disability, or any other cause, Xxxxxxx and the Bank agree that
Xxxxxxx shall be entitled to elect to defer into his Retirement
Account up to the following maximum amounts of the Compensation
that Xxxxxxx would otherwise be entitled to receive from the Bank
in each of the following Fiscal Year of the Bank:
Amount Deferred
1995 $10,000.00
1996 $11,000.00
1997 $12,100.00
1998 $13,310.00
1999 $14,641.00
2000 $16,105.00
2001 $17,716.00
2002 $19,487.00
2003 $21,436.00
2004 $23,579.00
The contemplated Annual Deferral Sum shall be deferred in
substantially equal bi-weekly amounts during each Fiscal Year or
portion thereof during which this Agreement is in effect. The
amount of Compensation actually deferred in any Fiscal Year,
taking into account discontinuance of deferral pursuant to a
Notice of Discontinuance, termination of Xxxxxxx'x employment,
the death of Xxxxxxx, or otherwise is hereinafter referred to as
the "Annual Deferred Amount." The portions of Xxxxxxx'x Annual
Deferred Amount deferred bi-weekly shall be credited to Xxxxxxx'x
Retirement Account bi-weekly, as Deferrals are accrued.
3. ADDITIONS TO DEFERRED AMOUNTS. The Bank hereby agrees
that it will credit Deferred Amounts in Xxxxxxx'x Retirement
Account with additions thereon ("Additions") from and after the
dates Deferred Amounts are credited to the Retirement Account,
subject to the limitations herein set forth. Additions to
Deferred Amounts, calculated at the rate of eight percent (8%)
per annum, compounded annually at the end of each Fiscal Year,
shall accrue commencing on the date the Retirement Account first
has a positive balance and shall continue until the first of the
following events to occur:
(a) The date that Death Benefits as described in
paragraph 7(b) hereof, Retirement Benefits, or Disability
Benefits, whichever applies, end hereunder; or
(b) The date on which Death Benefits as described in
paragraph 7(a) hereof commence; or
(c) The date on which a Termination Benefit or an
Acquisition Termination Benefit, as herein defined, is paid.
4. ELECTION TO DEFER COMPENSATION. Xxxxxxx may elect an
Annual Deferral Sum hereunder by filing an Election of Deferral.
The initial Election of Deferral must be filed within thirty (30)
days of the Effective Date of this Agreement. Such initial
Election of Deferral, if any, shall be effective commencing with
the first day of the first month after it is filed. Thereafter,
an Election of Deferral must be filed at least thirty (30) days
prior to the beginning of the Fiscal Year to which it pertains
and shall be effective on the first day of the Fiscal Year
following the filing thereof.
5. TERMINATION OF ELECTION. Xxxxxxx'x initial Election of
Deferral shall continue in effect, pursuant to the terms of the
Election of Deferral, unless and until Xxxxxxx files with the
Bank a Notice of Discontinuance or a subsequent Election of
Deferral specifying a different amount of deferral. Each
Election of Deferral filed subsequent to the initial Election of
Deferral shall similarly continue in effect until Xxxxxxx files a
Notice of Discontinuance or a new Election of Deferral. Any new
Election of Deferral, to be effective, must be filed at least
thirty (30) days prior to the beginning of the Fiscal Year in
which deferral is sought. A Notice of Discontinuance shall be
effective if filed at least twenty (20) days prior to any
January 1st, April 1st, July 1st or October 1st. Such Notice of
Discontinuance shall be effective commencing with the
January 1st, April 1st, July 1st or October 1st following its
filing, whichever applies, and shall apply only with respect to
Xxxxxxx'x Compensation and bonuses attributable to services not
yet performed.
6. RETIREMENT BENEFITS.
(a) Retirement Benefit. The Bank agrees that, from
and after the retirement of Xxxxxxx from the service of the
Bank upon reaching his Normal Retirement Date, the Bank
shall thereafter pay as a retirement benefit (herein
referred to as the "Retirement Benefit") to Xxxxxxx
Xxxxxxx'x entire Accrued Benefit, payable in equal annual
installments, due on the 31st day of January of each year
commencing on the first such date following the Normal
Retirement Date, for a period of fifteen (15) years. The
amount of each annual installment shall be an amount which,
if paid annually over the remainder of the fifteen (15) year
payment term, would result in payment of the entire Accrued
Benefit, together with interest accrued at the rate of eight
(8%) percent per annum, in equal annual installments.
(b) Election of Benefits Upon Normal Retirement Date.
Xxxxxxx shall have the option, upon attaining his Normal
Retirement Date, to elect to receive his Retirement Benefit,
notwithstanding his continued employment with the Bank after
he has attained his Normal Retirement Date. Xxxxxxx'x
election to receive his Retirement Benefit notwithstanding
his continued employment must be made in writing at least
ninety (90) days prior to his Normal Retirement Date. The
Retirement Benefit payable upon election pursuant to this
paragraph 6.b shall be the amount that would have been
payable had Xxxxxxx retired from service with the Bank as of
his Normal Retirement Date. Any such election shall be
irrevocable and shall result in the termination of Xxxxxxx'x
right to any further deferrals hereunder.
7. DEATH BENEFITS.
(a) Death Benefit Prior to Commencement of Retirement
or Disability Benefits. In the event of Xxxxxxx'x death
while in the employment of Bank and prior to commencement of
Retirement Benefits or Disability Benefits, Bank shall pay
to Xxxxxxx'x designated beneficiary, in accordance with the
last such designation received by the Bank from Xxxxxxx
prior to his death, a benefit in fifteen (15) annual
installments, each in the amount of Forty-Four Thousand Five
Hundred Sixty and 00/100 ($44,560.00). If no such
designation has been received by Bank from Xxxxxxx prior to
his death, or if said payments are otherwise to be made as
provided herein, said payments shall be made to Xxxxxxx'x
then-living spouse, so long as she shall live, and
thereafter to such person or persons, including her estate,
as she may appoint under her Will, making specific reference
hereto; if Xxxxxxx is not survived by a spouse, or if said
spouse shall be then deceased, having failed to so appoint,
then said payments shall be made to the then-living children
of Xxxxxxx, if any, in equal shares, for their joint and
survivor lives; and if none, or after their respective joint
and survivor lives, any balance thereof in one lump sum to
the estate of Xxxxxxx. Payments shall be due on January 31
of each year, commencing on the first such date occurring
after the death of Xxxxxxx. To the extent that the Accrued
Benefit in Xxxxxxx'x Retirement Account exceeds the total of
payments required under this section, such excess sums shall
be forfeited.
(b) Death Benefit After Commencement of Benefits. In
the event of Xxxxxxx'x death after the commencement of
Normal Retirement Benefits, but prior to the completion of
all such payments due and owing hereunder, the Bank shall
continue to make such payments, in equal annual
installments, over the remainder of the period specified in
paragraph 6 hereof that would have been applicable to
Xxxxxxx had he survived. Such continuing payments shall be
made to Xxxxxxx'x designated beneficiary, in accordance with
the last such designation received by the Bank from Xxxxxxx
prior to his death. If no such designation has been
received by the Bank from Xxxxxxx prior to his death or if
said payments are otherwise to be made as provided herein,
said payments shall be made to Xxxxxxx'x then living spouse,
so long as she shall live and thereafter to such person or
persons, including her estate, as she may appoint under her
Will, making specific reference hereto; if Xxxxxxx is not
survived by a spouse or if she shall fail to so appoint,
then said payments shall be made to the then living children
of Xxxxxxx, if any, in equal shares, for their joint and
survivor lives; and if none, or after their respective joint
and survivor lives, any balance thereof in one lump sum to
the estate of Xxxxxxx. Such continuing payments shall be
payable on January 31 of each year, commencing on the first
such date occurring after the death of Xxxxxxx.
8. DISABILITY BENEFIT. In the event that Xxxxxxx is
determined to be Disabled, as defined in the Blue Ball National
Bank Long Term Disability Plan (which definition is incorporated
herein and made a part hereof), then the date of such
determination shall, for purposes of this Agreement, be deemed to
be Xxxxxxx'x Normal Retirement Date, and all benefits otherwise
payable to Xxxxxxx following the Normal Retirement Date shall be
payable to Xxxxxxx as a Disability Benefit.
9. TERMINATION BENEFIT. In the event of Xxxxxxx'x
termination of employment with the Bank before his Normal
Retirement Date for any reason, other than his death or
Disability (as herein defined) or the occurrence of any
Acquisition Termination (as herein defined), the Bank shall pay
to Xxxxxxx, as compensation for services rendered prior to such
termination, a single sum equal to the total Deferred Amounts
hereunder, exclusive of Additions thereto (herein referred to as
the "Termination Benefit"). In the event of the payment of a
Termination Benefit, any and all Additions credited to Xxxxxxx'x
Retirement Account shall be forfeited to the Bank. The
Termination Benefit shall be payable on the first day of the
first month following the termination of Xxxxxxx'x employment
with the Bank.
10. ACQUISITION TERMINATION BENEFIT. In the event that
Bank or PennRock Financial Services Corp., of which Bank is a
wholly-owned subsidiary, should at any time prior to Xxxxxxx'x
Normal Retirement Date be acquired by any other entity, and in
the event that Xxxxxxx'x employment with Bank or its successor is
subsequently terminated involuntarily prior to Xxxxxxx'x Normal
Retirement Date, then such termination shall be deemed an
Acquisition Termination hereunder. In such event, Bank or its
successor shall pay to Xxxxxxx, as compensation for services
rendered prior to such termination, a single sum equal to the
total Deferred Amounts hereunder, together with all Additions
thereto (the "Acquisition Termination Benefit"). The Acquisition
Termination Benefit shall be payable on the first day of the
first month following the termination of Xxxxxxx'x employment
with the Bank or its successor.
11. HARDSHIP BENEFIT. In the event Xxxxxxx suffers a
financial hardship (as hereinafter defined), the Bank may, if it
deems advisable in its sole and absolute discretion, distribute
to or utilize on behalf of Xxxxxxx as a hardship benefit (the
"Hardship Benefit") any portion of Xxxxxxx'x Retirement Account
up to, but not in excess of, the Termination Benefit to which
Xxxxxxx would have been entitled as of the date a Hardship
Benefit is distributed or utilized. Any Hardship Benefit shall
be distributed or utilized at such times as the Bank shall
determine, and the Accrued Benefit in Xxxxxxx'x Benefit Account
shall be reduced by the amount so distributed and/or utilized.
Financial Hardship shall mean dire financial need of Xxxxxxx
caused by temporary or permanent disability or incapacity,
medical or educational expenses, the purchase or maintenance of a
residence, or a material reduction in family income.
12. OFFSET FOR OBLIGATIONS TO BANK. If, at such time as
Xxxxxxx becomes entitled to benefit payments hereunder, Xxxxxxx
has any debt, obligation or other liability representing an
amount owing to the Bank or an Affiliate of the Bank, and if such
debt, obligation, or other liability is due and owing at the time
benefit payments are payable hereunder, the Bank may offset the
amount owing it or an Affiliate against the amount of benefits
otherwise distributable hereunder.
13. BENEFICIARY DESIGNATION. Xxxxxxx shall have the right,
at any time, to submit in substantially the form attached hereto
as Exhibit "C," a written designation of primary and secondary
beneficiaries to whom payment under this Agreement shall be made
in the event of his death prior to complete distribution of the
benefits due and payable under the Agreement. Each beneficiary
designation shall become effective only when receipt thereof is
acknowledged in writing by the Bank.
14. NO TRUST CREATED. Nothing created in this Agreement,
and no action taken pursuant to its provisions by either party
hereto shall create, or be construed to create, a trust of any
kind, or a fiduciary relationship between the Bank and Xxxxxxx,
his designated beneficiary, other beneficiaries of Xxxxxxx or any
other person.
15. BENEFITS PAYABLE ONLY FROM GENERAL CORPORATE ASSETS;
UNSECURED GENERAL CREDITOR STATUS OF XXXXXXX.
(a) The payments to Xxxxxxx or his designated
beneficiary or any other beneficiary hereunder shall be made
from assets which shall continue, for all purposes, to be a
part of the general, unrestricted assets of the Bank; no
person shall have any interest in any such assets by virtue
of the provisions of this Agreement. The Bank's obligation
hereunder shall be an unfunded and unsecured promise to pay
money in the future. To the extent that any person acquires
a right to receive payments from the Bank under the
provisions hereof, such right shall be no greater than the
right of any unsecured creditor of the Bank, no such person
shall have nor require any legal or equitable right,
interest or claim in or to any property or assets of the
Bank.
(b) This promise of future payment by Bank to Xxxxxxx
shall be unfunded and unsecured and shall not be construed
as a transfer of any present right to receive payment.
Xxxxxxx shall derive no present economic benefit from this
Agreement. In the event that, in its discretion, the Bank
purchases an insurance policy or policies insuring the life
of Xxxxxxx (or any other property), to allow the Bank to
recover the cost of providing benefits, in whole or in part,
hereunder, neither Xxxxxxx, his designated beneficiary nor
any other beneficiary shall have any rights whatsoever
therein or in the proceeds therefrom. The Bank shall be the
sole owner and beneficiary of any such insurance policy and
shall possess and may exercise all incidents of ownership
therein. No such policy, policies or other property shall
be held in any trust for Xxxxxxx or any other person nor as
collateral security for any obligation of the Bank
hereunder.
16. NO CONTRACT OF EMPLOYMENT. Nothing contained herein
shall be construed to be a contract of employment for any term of
years, nor as conferring upon Xxxxxxx the right to continue to be
employed by the Bank in his present capacity, or in any capacity.
It is expressly understood by the parties hereto that this
Agreement relates to the payment of deferred compensation for
Xxxxxxx'x services, payable after termination of his employment
with the Bank, and is not intended to be an employment contract.
17. BENEFITS NOT TRANSFERABLE. Neither Xxxxxxx, his
designated beneficiary, nor any other beneficiary under this
Agreement shall have any power or right to transfer, assign,
anticipate, hypothecate or otherwise encumber any part or all of
the amounts payable hereunder. No such amounts shall be subject
to seizure by any creditor of any such beneficiary, by a
proceeding at law or in equity, nor shall such amounts be
transferable by operation of law in the event of bankruptcy,
insolvency or death of Xxxxxxx, his designated beneficiary, or
any other beneficiary hereunder. Any such attempted assignment
or transfer shall be void.
18. DETERMINATION OF BENEFITS.
(a) Claim.
A person who believes that he is being denied a benefit
to which he is entitled under the Plan (hereinafter referred
to as a "Claimant") may file a written request for such
benefit with the Bank, setting forth his claim. The request
must be addressed to any Senior Vice President of the Bank
at its then principal place of business.
(b) Claim Decision.
Upon receipt of a claim, the Bank shall advise the
Claimant that a reply will be forthcoming within ninety (90)
days and shall, in fact, deliver such reply within such
period. The Bank may, however, extend the reply period for
an additional ninety (90) days for reasonable cause.
If the claim is denied in whole or in part, the Bank
shall adopt a written opinion, using language calculated to
be understood by the Claimant, setting forth:
(i) The specific reason or reasons for such
denial;
(ii) The specific reference to pertinent
provisions of this Agreement on which such denial is based;
(iii) A description of any additional material or
information necessary for the Claimant to perfect his claim
and an explanation why such material or such information is
necessary;
(iv) Appropriate information as to the steps to
be taken if the Claimant wishes to submit the claim for
review; and
(v) The time limits for requesting a review under
subsection c. and for review under subsection d. hereof.
(c) Request for Review.
Within sixty (60) days after the receipt by the
Claimant of the written opinion described above, the
Claimant may request in writing that the Secretary of the
Bank review the determination of the Bank. Such request
must be addressed to the Secretary of the Bank, at its then
principal place of business. The Claimant or his duly
authorized representative may, but need not, review the
pertinent documents and submit issues and comments in
writing for consideration by the Bank. If the Claimant does
not request a review of the Bank's determination by the
Secretary of the Bank within such sixty (60) day period, he
shall be barred and estopped from challenging the Bank's
determination.
(d) Review of Decision.
Within sixty (60) days after the Secretary's receipt of
a request for review, he will review the Bank's
determination. After considering all materials presented by
the Claimant, the Secretary will render a written opinion,
written in a manner calculated to be understood by the
Claimant, setting forth the specific reasons for the
decision and containing specific references to the pertinent
provisions of this Agreement on which the decision is based.
If special circumstances require that the sixty (60) day
time period be extended, the Secretary will so notify the
Claimant and will render the decision as soon as possible,
but no later than one hundred twenty (120) days after
receipt of the request for review.
19. AMENDMENT. This Agreement may not be amended, altered
or modified, except by a written instrument signed by the parties
hereto, or their respective successors, and may not be otherwise
terminated except as provided herein.
20. INUREMENT. This Agreement shall be binding upon and
inure to the benefit of the Bank and its successors and assigns,
and Xxxxxxx, his successors, heirs, executors, administrators and
beneficiaries.
21. NOTICE. Any notice, consent or demand required or
permitted to be given under the provisions of this Agreement
shall be in writing, and shall be signed by the party giving or
making the same. If such notice, consent or demand is mailed to
a party hereto, it shall be sent by United States certified mail,
postage prepaid, addressed to such party's last known address as
shown on the records of the Bank. The date of such mailing shall
be deemed the date of notice, consent or demand. Either party
may change the address to which notice is to be sent by giving
notice of the change of address in the manner aforesaid.
22. GOVERNING LAW. This Agreement, and the rights of the
parties hereunder, shall be governed by and construed in
accordance with the laws of the United States of America and of
the Commonwealth of Pennsylvania.
IN WHEREOF, the parties have executed this Agreement, in
duplicate, as of the day and year first above written.
ATTEST: BLUE BALL NATIONAL BANK
___________________________ By:______________________________
XXXXXX X. XXXXXX, Secretary XXXXXX XXXXX, XX.,
Vice President
____________________________(SEAL)
XXXXXX XXXXXXX Exhibit A
ELECTION OF DEFERRAL
TO: BLUE BALL NATIONAL BANK
Attention: Payroll Department
I hereby elect to defer a portion of my annual compensation
under the following Schedule:
Amount Deferred
1995 $10,000.00
1996 $11,000.00
1997 $12,100.00
1998 $13,310.00
1999 $14,641.00
2000 $16,105.00
2001 $17,716.00
2002 $19,487.00
2003 $21,436.00
2004 $23,579.00
I further authorize Blue Ball National Bank to credit all amounts
so deferred to the Retirement Account established pursuant to
that certain Xxxxxx Xxxxxxx Deferred Compensation Plan Agreement,
by and between the undersigned and Blue Ball National Bank, dated
the _____ day of _____________, 1995.
I understand that this authorization shall remain in effect
until revoked or amended. I understand that I may revoke
deferral upon at least 20 days' prior written notice, effective
on any January 1st, April 1st, July 1st or October 1st. I
further understand that I may file an amended Election of
Deferral at least 30 days prior to the beginning of a Fiscal Year
of the Bank, effective on the first day of such Fiscal Year.
Date: _________________ ______________________________
Xxxxxx Xxxxxxx Exhibit B
NOTICE OF DISCONTINUANCE
TO: BLUE BALL NATIONAL BANK
Attention: Payroll Department
I hereby give notice of my election to discontinue deferral
of my Compensation under that certain Xxxxxx Xxxxxxx Deferred
Compensation Plan Agreement, by and between Blue Ball National
Bank and the undersigned, dated the _____ day of ______________,
1995. This notice is submitted at least twenty (20) days prior
to January 1st, April 1st, July 1st, or October 1st, and shall be
effective as of such date, as specified below.
Discontinue deferral as of [ ] January 1st, 19__
(xxxx one) [ ] April 1st, 19__
[ ] July 1st, 19__
[ ] October 1st, 19__
____________________________
Xxxxxx Xxxxxxx
Dated:______________________
Exhibit C
DESIGNATION OF BENEFICIARY
UNDER THE
XXXXXX XXXXXXX
DEFERRED COMPENSATION PLAN AGREEMENT
I. Employee: Xxxxxx Xxxxxxx
XX. The above-named Employee's Revocable Beneficiary under the
Xxxxxx Xxxxxxx Deferred Compensation Plan Agreement is set
forth below (CHECK BOX TO LEFT OF APPLICABLE NUMBERED
SUBPARAGRAPH AND FILL IN THE BLANK(S); CHECK AND COMPLETE
ONLY ONE NUMBERED SUBPARAGRAPH):
[x] 1. Employee's spouse, Xxxx X. Xxxxxxx, if living at the
Employee's death; if not, such of the children of the
marriage of the Employee and said spouse as shall be
then living, equally, or the issue of any deceased
child per stirpes.
[ ] 2. Employee's spouse, _______________________, if living
at the Employee's death, if not, such of the Employee's
children as shall be then living, equally.
[ ] 3. Such of the following children of the Employee as shall
be living at the Employee's death, equally:
_________________________, __________________________,
_____________________________________________________.
[ ] If this box is checked, and if paragraph 1, 2 or 3 is
checked, then the living children of any deceased child
designated shall take the share, divided equally, which
such child would have taken, if living.
[ ] 4. Employee's ______________________, if living at the
Employee's death, if not, Employee's ________________,
if then living, if not, Employee's ________________, if
then living.
(Insert relationship to Employee and name).
[ ] 5. Such of the following as shall be living at the
Employee's death, equally: Employee's _______________
______________________________________________________.
(Insert relationship to Employee and name).
[ ] 6. Employee's _________________________, if living at the
Employee's death.