THIS DOCUMENT CONSTITUTES PART OF A PROSPECTUS COVERING SECURITIES THAT HAVE BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933. THE SCOTTS MIRACLE-GRO COMPANY 2006 LONG-TERM INCENTIVE PLAN AWARD AGREEMENT FOR EMPLOYEES [FORM OF AWARD] AWARDED TO...
EXHIBIT
10.5
GERMAN FORM
THIS DOCUMENT CONSTITUTES PART OF A PROSPECTUS COVERING SECURITIES
THAT HAVE BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933.
THAT HAVE BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933.
THE SCOTTS MIRACLE-GRO COMPANY
2006 LONG-TERM INCENTIVE PLAN
2006 LONG-TERM INCENTIVE PLAN
AWARD AGREEMENT FOR EMPLOYEES
[FORM OF AWARD] AWARDED TO [XXXXXXX’S NAME] ON [XXXXX XXXX]
The Scotts Miracle-Gro Company (“Company”) and its shareholders believe that their business
interests are best served by ensuring that you have an opportunity to share in the Company’s
business success. To this end, the Company adopted and its shareholders approved The Scotts
Miracle-Gro Company 2006 Long-Term Incentive Plan (“Plan”) through which key employees, like you,
may acquire (or share in the appreciation of) common shares of the Company.
We cannot guarantee that the value of your Award (or the value of the common shares you acquire
through an Award) will increase. This is because the value of the Company’s common shares is
affected by many factors. However, the Company believes that your efforts contribute to the value
of the Company’s common shares and that the Plan (and the Awards made through the Plan) is an
appropriate means of sharing with you the value of your contribution to the Company’s business
success.
This Award Agreement describes the type of Award that you have been granted and the conditions that
must be met before you may receive the value associated with your Award. To ensure you fully
understand these terms and conditions, you should:
• | Read the Plan and the Plan’s Prospectus, as supplemented, carefully to ensure you understand how the Plan works; | ||
• | Read this Award Agreement carefully to ensure you understand the nature of your Award and what you must do to earn it; and | ||
• | Contact [Contact’s Name at Company], [Contact’s Title] at [Telephone Number] if you have any questions about your Award. Or, you may send a written inquiry to the address shown below: |
The Scotts Miracle-Gro Company
Attention: [Contact’s Name at Company]
[Contact’s Title]
00000 Xxxxxxxxxx Xxxx
Xxxxxxxxxx, Xxxx 00000
Attention: [Contact’s Name at Company]
[Contact’s Title]
00000 Xxxxxxxxxx Xxxx
Xxxxxxxxxx, Xxxx 00000
You must return a signed copy of this Award Agreement no later than [__ Days Post Grant Date] to:
[Third Party Administrator]
Attention: [TPA Contact’s Name]
[Contact’s Address]
Attention: [TPA Contact’s Name]
[Contact’s Address]
[TPA Telephone Number]
GERMAN FORM
If you do not do this, your Award will be forfeited and you will not be entitled to receive
anything on account of this Award.
GERMAN FORM
Description of Your Nonqualified Stock Options
You have been awarded Nonqualified Stock Options (or “NSOs”) to purchase [Number Granted] common
shares of the Company. You may purchase one of the Company’s common shares for each NSO, but only
if you pay US $[Price] (“Exercise Price”) for each common share you purchase, you exercise the NSOs
on or before [Expiration Date] (“Expiration Date”) and you meet the terms and conditions described
in this Award Agreement, the Plan and the Prospectus, as supplemented. You also must arrange to
pay any taxes due on exercise using one of the procedures described later in this Award Agreement.
Limits on Exercising Your NSOs
Normally, your NSOs will vest (and become exercisable) on [Vesting Date] but only if you are
actively employed by the Company or any Subsidiary or Affiliate (as defined in the Plan) on
[Vesting Date] and all other conditions described in this Award Agreement, the Plan and the
Prospectus, as supplemented, are met.
This does not mean that you must exercise your NSOs on this date; this is merely the first date
that you may do so. However, your NSOs will expire unless they are exercised on or before the
Expiration Date ([Expiration Date]).
There are some special situations in which your NSOs may vest earlier. These are described later
in this Award Agreement.
At any one time, you may not exercise NSOs to buy fewer than 100 common shares of the Company (or,
if smaller, the number of your outstanding vested NSOs). Also, you may never exercise an NSO to
purchase a fractional common share of the Company; NSOs for fractional common shares will always be
redeemed for cash.
Exercising Your NSOs
After they vest, you may exercise your NSOs by completing an Exercise Notice. A copy of this
Exercise Notice is attached to this Award Agreement. Also, a copy of this Exercise Notice and a
description of the procedures that you must follow to exercise your NSOs are available from [Third
Party Administrator] at [TPA Telephone Number] or at the address shown below.
You may use one of three methods to exercise your NSOs and to pay any taxes related to that
exercise. You will decide on the method at the time of exercise.
Cashless Exercise and Sell: If you elect this alternative, you will be deemed to have
simultaneously exercised the NSOs and to have sold the common shares underlying those NSOs.
When the transaction is complete, you will receive cash (but no common shares of the
Company) equal to the difference between the aggregate value of the common shares deemed to
have been acquired through the exercise minus the NSOs’ aggregate exercise price and related
taxes.
Combination Exercise: If you elect this alternative, you will be deemed to have
simultaneously exercised the NSOs and to have sold a number of those common shares with a
value equal to the NSOs’ aggregate exercise price and related taxes. When the transaction
is complete, the balance of the common shares subject to the NSOs you exercised will be
transferred to you.
GERMAN FORM
Exercise and Hold: If you elect this alternative, you must pay the full exercise price plus
related taxes (in cash, a cash equivalent or in common shares of the Company having a value
equal to the exercise price and which you have owned for at least six months before the
exercise date). When the transaction is complete, you will receive one common share for
each NSO exercised.
Before choosing an exercise method, you should read the Prospectus, as supplemented, to ensure you
understand the federal income tax effect of exercising your NSOs and of the exercise method you
choose.
If you do not elect one of these methods, we will apply the Cashless Exercise and Sell method
described above.
Tax Treatment of Your NSOs
The federal income tax treatment of your NSOs is discussed in the Plan’s Prospectus, as
supplemented.
*****
General Terms and Conditions
You May Forfeit Your NSOs if Your Employment Ends
Normally, you may exercise your NSOs after they vest and before the Expiration Date ([Expiration
Date]). However, to the extent permitted by law, your NSOs may be cancelled earlier than the
Expiration Date if you terminate employment before [Vesting Date].
[a] If your employment is terminated for “cause” (as defined in the Plan), the NSOs will
expire on the date your employment ends; or
[b] If your employment is terminated because of your [i] death or [ii] disability (as
defined in the Plan), the NSOs will expire on the earlier of the Expiration Date or 12
months after you terminate; or
[c] If your employment is terminated after you have reached either [i] age 55 and completed
at least 10 years of employment or [ii] age 62 regardless of your years of service, the NSOs
will expire on the earlier of the Expiration Date or 12 months after you terminate; or
[d] If your employment is terminated for any reason other than “cause,” death or disability,
your NSOs will expire on the earlier of the Expiration Date or 90 days after you terminate.
Note: it is your responsibility to keep track of when your NSOs expire.
You May Forfeit Your NSOs if You Engage in Conduct That is Harmful to the Company (or any Affiliate
or Subsidiary)
To the extent permitted by law, you also will forfeit any outstanding NSOs and must return to the
Company all common shares and other amounts you have received through the Plan if, without our
consent, you do any of the following within 180 days before and 730 days after terminating
employment (as defined in the Plan) with the Company or any Affiliate or Subsidiary:
[a] You serve (or agree to serve) as an officer, director, consultant or employee of any
proprietorship, partnership, corporation or other entity or become the owner of a business
or a member of a partnership that competes with any portion of the Company’s (or any
Affiliate’s or
GERMAN FORM
Subsidiary’s) business with which you have been involved any time within five years before
termination of employment or render any service (including, without limitation, advertising
or business consulting) to entities that compete with any portion of the Company’s (or any
Affiliate’s or Subsidiary’s) business with which you have been involved any time within five
years before termination of employment;
[b] You refuse or fail to consult with, supply information to or otherwise cooperate with
the Company or any Affiliate or Subsidiary after having been requested to do so;
[c] You deliberately engage in any action that the Company concludes has caused substantial
harm to the interests of the Company or any Affiliate or Subsidiary;
[d] On your own behalf or on behalf of any other person, partnership, association,
corporation or other entity, you solicit or in any manner attempt to influence or induce any
employee of the Company or any Affiliate or Subsidiary to leave the Company’s or any
Affiliate’s or Subsidiary’s employment or use or disclose to any person, partnership,
association, corporation or other entity any information obtained while an employee of the
Company or any Affiliate or Subsidiary concerning the names and addresses of the Company’s
or any Affiliate’s or Subsidiary’s employees;
[e] You disclose confidential and proprietary information relating to the Company’s or any
Affiliate’s or Subsidiary’s business affairs (“Trade Secrets”), including technical
information, product information and formulae, processes, business and marketing plans,
strategies, customer information and other information concerning the Company’s or any
Affiliate’s or Subsidiary’s products, promotions, development, financing, expansion plans,
business policies and practices, salaries and benefits and other forms of information
considered by the Company or any Affiliate or Subsidiary to be proprietary and confidential
and in the nature of Trade Secrets;
[f] You fail to return all property (other than personal property), including keys, notes,
memoranda, writings, lists, files, reports, customer lists, correspondence, tapes, disks,
cards, surveys, maps, logs, machines, technical data, formulae or any other tangible
property or document and any and all copies, duplicates or reproductions that you have
produced or received or have otherwise been submitted to you in the course of your
employment with the Company or any Affiliate or Subsidiary; or
[g] You engaged in conduct that the Committee (as defined in the Plan) reasonably concludes
would have given rise to a termination for “cause” (as defined in the Plan) had it been
discovered before you terminated your employment.
Your NSOs May Vest Earlier Than Described Above. Normally, your NSOs will vest only in the
circumstances described above. However, if there is a “Change in Control” (as defined in the
Plan), your NSOs may vest earlier. You should read the Plan and the Prospectus carefully to ensure
that you understand how this may happen.
Amendment/Termination. We may amend or terminate the Plan at any time.
Rights Before Your NSOs Are Exercised: You may not vote, or receive any dividends associated with,
the common shares underlying your NSOs.
Beneficiary Designation: You may name a beneficiary or beneficiaries to receive or to exercise any
vested NSOs that are unexercised when you die. This may be done only on the attached Beneficiary
GERMAN FORM
Designation Form and by following the rules described in that Form. The Beneficiary Designation
Form need not be completed now and is not required as a condition of receiving your Award. If you
die without completing a Beneficiary Designation Form or if you do not complete that Form
correctly, your beneficiary will be your surviving spouse or, if you do not have a surviving
spouse, your estate.
Transferring Your NSOs: Normally your NSOs may not be transferred to another person. However, you
may complete a Beneficiary Designation Form to name the person who may exercise your NSOs if you
die before their Expiration Date. Also, the Committee may allow you to place your NSOs into a
trust established for your benefit or for the benefit of your family. Contact [Third Party
Administrator] at [TPA Telephone Number] or at the address given below if you are interested in
doing this.
Governing Law: This Award Agreement will be construed in accordance with and governed by the laws
of the United States of America and of the State of Ohio (other than laws governing conflicts of
laws).
Other Agreements: Also, your NSOs will be subject to the terms of any other written agreements
between you and the Company or any Affiliate or Subsidiary to the extent that those other
agreements do not directly conflict with the terms of the Plan or this Award Agreement.
Adjustments to NSOs: Your NSOs will be adjusted, if appropriate, to reflect any change to the
Company’s capital structure (e.g., the number of your NSOs and the Exercise Price will be adjusted
to reflect a stock split).
No Right to Employment: Your award of NSOs is a voluntary, discretionary bonus being made on a
one-time basis and it does not constitute a commitment to make any future awards. This award of
NSOs and any payments made hereunder will not be considered salary or other compensation for
purposes of any severance pay or similar allowance, except as otherwise required by law. Nothing
in this Award Agreement will give you any right to continue employment with the Company or any
Subsidiary or Affiliate, as the case may be, or interfere in any way with the right of the Company
or a Subsidiary or an Affiliate to terminate your employment.
Data Privacy: Information about you and your participation in the Plan, including, but not limited
to, your name, home address and telephone number, date of birth, social insurance number, salary,
nationality, job title, any shares of stock or directorships held in the Company, details of all
NSOs or other entitlement to shares of stock awarded, cancelled, exercised, vested, unvested or
outstanding in your favor, may be collected, recorded, held, used and disclosed for any purpose
related to the administration and management of the Plan and in order to satisfy legal and
regulatory requirements. You understand that the Company will keep your personal data in
accordance with the rules set forth by Law No. 78-17, dated January 6, 1978, related to “software,
files and liberties” (the “Law”). The Company will also take reasonable measures in order to
protect your personal data and to observe the requirements set forth in the Commission
Nationale de l’Informatique et des Libertés. Pursuant to the Law, you have the right to access
and correct your personal data. You also understand that the Company and its Subsidiaries or
Affiliates may transfer such information to any third party administrators, regardless of whether
such persons are located within your country of residence, the European Economic Area or in
countries outside of the European Economic Area, including the United States of America, where the
rules protecting such data are less stringent than those applicable within the European Economic
Area. You consent to the processing of information relating to you and your participation in the
Plan in any one or more of the ways referred to above.
Other Rules: Your NSOs also are subject to more rules described in the Plan and in the Plan’s
Prospectus, as supplemented. You should read both of these documents carefully to ensure you fully
understand all the terms and conditions of the grant of NSOs made to you under this Award
Agreement.
*****
You may contact [Third Party Administrator] at [TPA Telephone Number] or at the address given below
if you have any questions about your Award or this Award Agreement.
GERMAN FORM
Your Acknowledgment of Award Conditions
Note: You must sign and return a copy of this Award Agreement to [Third Party Administrator] at
the address given below no later than [___Days Post Grant Date].
By signing below, I acknowledge and agree that:
• | A copy of the Plan has been made available to me; | ||
• | I have received a copy of the Plan’s Prospectus, as supplemented; | ||
• | I understand and accept the conditions placed on my NSOs and understand what I must do to earn and exercise my NSOs. I also have had the opportunity to seek advice from independent counsel regarding the terms and conditions of my NSOs; | ||
• | I will consent (on my own behalf and on behalf of my beneficiaries and without any further consideration) to any necessary change to my NSOs or this Award Agreement to comply with any law and to avoid paying penalties under Section 409A of the U.S. Internal Revenue Code, even if those changes affect the terms of my NSOs and reduce their value or potential value; and | ||
• | If I do not return a signed copy of this Award Agreement to the address shown below on or before [___Days Post Grant Date], my NSOs will be forfeited and I will not be entitled to receive anything on account of this Award. |
[Xxxxxxx’s Name] | THE SCOTTS MIRACLE-GRO COMPANY | |||||||
By:
|
By: | |||||||
Date signed:
|
Name: | |||||||
Title: | ||||||||
Date signed: | ||||||||
A signed copy of this Award Agreement must be sent to the following address no later than [___Days
Post Grant Date]:
[Third Party Administrator]
Attention: [TPA Contact’s Name]
[Contact’s Address]
Attention: [TPA Contact’s Name]
[Contact’s Address]
[TPA Telephone Number]
After it is received, The Scotts Miracle-Gro Company 2006 Long-Term Incentive Plan Committee will
acknowledge receipt of your signed Award Agreement.
GERMAN FORM
THE SCOTTS MIRACLE-GRO COMPANY
2006 LONG-TERM INCENTIVE PLAN
2006 LONG-TERM INCENTIVE PLAN
NONQUALIFIED STOCK OPTION EXERCISE NOTICE
AFFECTING NONQUALIFIED STOCK OPTIONS GRANTED TO
[XXXXXXX’S NAME] ON [GRANT DATE]
[XXXXXXX’S NAME] ON [GRANT DATE]
Additional copies of this Nonqualified Stock Option Exercise Notice (and any further information
you may need about this Exercise Notice or exercising your NSOs) are available from [Third Party
Administrator] at the address given below.
By completing this Exercise Notice and returning it to [Third Party Administrator] at the address
given below, I elect to exercise the NSOs described below:
NOTE: You must complete a separate Nonqualified Stock Option Exercise Notice each time you exercise
NSOs granted under each Award Agreement (e.g., if you are exercising 200 NSOs granted January 1,
2007 and 100 NSOs granted January 1, 2008 under a separate award agreement, you must complete two
Nonqualified Stock Option Exercise Notices, one for each set of NSOs being exercised).
AFFECTED NSOS: This exercise relates to the following NSOs (fill in the blanks):
GRANT DATE: [GRANT DATE]
NUMBER OF NSOS BEING EXERCISED WITH THIS EXERCISE NOTICE:
EXERCISE PRICE: The Exercise Price due is US $
NOTE: This amount must be the product of US $[Price] multiplied by the number of NSOs being
exercised.
PAYMENT OF EXERCISE PRICE: I have decided to pay the Exercise Price and any
related taxes by (check one):
NOTE: These methods are described in the Award Agreement.
___ | Cashless Exercise and Sell. | ||
___ | Combination Exercise. | ||
___ | Exercise and Hold. |
Note:
• | If you select the Exercise and Hold method of exercise, you must also follow the procedures described in the Award Agreement to pay the Exercise Price and the taxes related to this exercise. You should contact [Third Party Administrator] at the address given below to find out the amount of the taxes due. |
GERMAN FORM
• | If you select either the Cashless Exercise and Sell or the Combination Exercise methods of paying the Exercise Price, you should contact [Third Party Administrator] at the address given below to be sure you understand how your choice of payment will affect the number of common shares of the Company you will receive. |
GERMAN FORM
YOUR ACKNOWLEDGEMENT OF EFFECT OF EXERCISE
By signing below, I acknowledge and agree that:
• | I fully understand the effect (including the investment effect) of exercising my NSOs and buying common shares of the Company and understand that there is no guarantee that the value of these common shares will appreciate or will not depreciate; | ||
• | This Exercise Notice will have no effect if it is not returned to [Third Party Administrator] at the address given below before the Expiration Date specified in the Award Agreement under which these NSOs were granted; and | ||
• | The common shares of the Company I am buying by completing and returning this Exercise Notice will be issued to me as soon as administratively practicable. |
[Grantee’s Name]
(signature)
Date signed:
A signed copy of this Nonqualified Stock Option Exercise Notice must be sent to the following
address no later than the Expiration Date:
[Third Party Administrator]
Attention: [TPA Contact’s Name]
[Contact’s Address]
Attention: [TPA Contact’s Name]
[Contact’s Address]
[TPA Telephone Number]
*****
GERMAN FORM
ACKNOWLEDGEMENT OF RECEIPT
A signed copy of this Nonqualified Stock Option Exercise Notice was received on:
.
.
[Xxxxxxx’s Name]:
___ | Has effectively exercised the NSOs described in this Notice; or | ||
___ | Has not effectively exercised the NSOs described in this Notice because |
describe deficiency
The Scotts Miracle-Gro Company 2006 Long-Term Incentive Plan Committee
By: |
||||
Date: |
||||
Note: Keep a copy of this Exercise Notice as part of the Plan’s permanent records.
GERMAN FORM
Your Acknowledgment of Award Conditions
Note: You must sign and return a copy of this Award Agreement to [Third Party Administrator] at
the address given below no later than [___Days Post Grant Date].
By signing below, I acknowledge and agree that:
• | A copy of the Plan has been made available to me; | ||
• | I have received a copy of the Plan’s Prospectus, as supplemented; | ||
• | I understand and accept the conditions placed on my Award and understand what I must do to earn my Award. I also have had the opportunity to seek advice from independent counsel regarding the terms and conditions of my Award; | ||
• | I will consent (on my own behalf and on behalf of my beneficiaries and without any further consideration) to any necessary change to my Award or this Award Agreement to comply with any law and to avoid paying penalties under Section 409A of the U.S. Internal Revenue Code, even if those changes affect the terms of my Award and reduce their value or potential value; and | ||
• | If I do not return a signed copy of this Award Agreement to the address shown below on or before [___Days Post Grant Date], my Award will be forfeited and I will not be entitled to receive anything on account of this Award. |
[Xxxxxxx’s Name] | THE SCOTTS MIRACLE-GRO COMPANY | |||||||
By:
|
By: | |||||||
Date signed:
|
Name: | |||||||
Title: | ||||||||
Date signed: | ||||||||
A signed copy of this Award Agreement must be sent to the following address no later than [___Days
Post Grant Date]:
[Third Party Administrator]
Attention: [TPA Contact’s Name]
[Contact’s Address]
Attention: [TPA Contact’s Name]
[Contact’s Address]
[TPA Telephone Number]
After it is received, The Scotts Miracle-Gro Company 2006 Long-Term Incentive Plan Committee will
acknowledge receipt of your signed Award Agreement.
GERMAN FORM
Committee’s Acknowledgment of Receipt
A signed copy of this Award Agreement was received on .
By:
[Grantee’s Name]
___Has complied with the conditions imposed on the grant and the Award Agreement remains
in effect; or
___Has not complied with the conditions imposed on the grant and the [Name of Award(s)]
are forfeited because .
describe deficiency
describe deficiency
The Scotts Miracle-Gro Company 2006 Long-Term Incentive Plan Committee
By: |
||||
Date: |
||||
Note: Send a copy of this completed Award Agreement to [Xxxxxxx’s Name] and keep a copy as part of
the Plan’s permanent records.
GERMAN FORM
THE SCOTTS MIRACLE-GRO COMPANY
2006 LONG-TERM INCENTIVE PLAN
2006 LONG-TERM INCENTIVE PLAN
BENEFICIARY DESIGNATION FORM
RELATING TO [FORM OF AWARD] AWARD GRANTED TO
[XXXXXXX’S NAME] ON [GRANT DATE]
RELATING TO [FORM OF AWARD] AWARD GRANTED TO
[XXXXXXX’S NAME] ON [GRANT DATE]
1.00 Instructions for Completing This Beneficiary Designation Form
You may use this Beneficiary Designation Form to [1] name the person you want to receive any amount
due under The Scotts Miracle-Gro Company 2006 Long-Term Incentive Plan after your death or [2]
change the person who will receive these benefits.
There are several things you should know before you complete this Beneficiary Designation Form.
First, if you do not elect a beneficiary, any amount due to you under the Plan when you die will be
paid to your surviving spouse or, if you have no surviving spouse, to your estate.
Second, your election will not be effective (and will not be implemented) unless you complete all
applicable portions of this Beneficiary Designation Form and return it to [Third Party
Administrator] at the address given below.
Third, all elections will remain in effect until they are changed (or until all death benefits are
paid).
Fourth, if you designate your spouse as your beneficiary but are subsequently divorced from that
person (or your marriage is annulled), your beneficiary designation will be revoked automatically.
Fifth, if you have any questions about this Beneficiary Designation Form or if you need additional
copies of this Form, please contact [Third Party Administrator] at [TPA Telephone Number] or at the
address or number given below.
1.00 Designation of Beneficiary
1.01 Primary Beneficiary:
I designate the following person(s) as my Primary Beneficiary or Beneficiaries to receive any
amount due after my death under the terms of the Award Agreement described at the top of this
Beneficiary Designation Form. This benefit will be paid, in the proportion specified, to:
% to | ||||||||||
(Name) | (Relationship) | |||||||||
Address: | ||||||||||
% to | ||||||||||
(Name) | (Relationship) | |||||||||
Address: | ||||||||||
GERMAN FORM
% to | ||||||||||
(Name) | (Relationship) | |||||||||
Address: | ||||||||||
% to | ||||||||||
(Name) | (Relationship) | |||||||||
Address: | ||||||||||
1.02 Contingent Beneficiary
If one or more of my Primary Beneficiaries die before I die, I direct that any amount due
after my death under the terms of the Award described at the top of this Beneficiary Designation
Form:
___Be paid to my other named Primary Beneficiaries in proportion to the allocation given
above (ignoring the interest allocated to the deceased Primary Beneficiary); or
___Be distributed among the following Contingent Beneficiaries:
% to | ||||||||||
(Name) | (Relationship) | |||||||||
Address: | ||||||||||
% to | ||||||||||
(Name) | (Relationship) | |||||||||
Address: | ||||||||||
% to | ||||||||||
(Name) | (Relationship) | |||||||||
Address: | ||||||||||
% to | ||||||||||
(Name) | (Relationship) | |||||||||
Address: | ||||||||||
Elections made on this Beneficiary Designation Form will be effective only after this Form is
received by [Third Party Administrator] and only if it is fully and properly completed and signed.
received by [Third Party Administrator] and only if it is fully and properly completed and signed.
[Grantee’s Name]
Date of Birth: |
||
Address: |
||
Sign and return this Beneficiary Designation Form to [Third Party Administrator] at the
address given below.
Date
|
Signature |
GERMAN FORM
Return this signed Beneficiary Designation Form to [Third Party Administrator] at the following
address:
[Third Party Administrator]
Attention: [TPA Contact’s Name]
[Contact’s Address]
Attention: [TPA Contact’s Name]
[Contact’s Address]
[TPA Telephone Number]
Received on:
By: