Your Personal Information
Legal Name:(First, Middle, Last)

Child
Social Security Number:
Date of Birth:(MM/DD/YYYY)
Types of Other Relationship
(e.g.neice or nephew)
Physical Address:
City
State
Zip
Mailing Address:(If different from physical address)
City
State
Zip
Home Phone Number:
Cell Phone:
Fax Number:
Online Statements:
Yes No
Email Notifications with Account Changes:
Yes No
Email Address:

Who are your Beneficiaries?
If the Primary or Contingent box is not checked for a beneficiary, the beneficiary will be deemed to be a Primary Beneficiary. In the event of my death, the balance in the account shall be paid to the Primary Beneficiaries who survive me in equal shares (or in the specified share, as indicated). If none of the Primary Beneficiaries survive me, the balance in the account shall be paid to the Contingent Beneficiaries who survive me in equal shares (or in the specified share, as indicated). If any Primary or Contingent Beneficiary does not survive me, such beneficiary's interest and the interest of such beneficiary's heirs shall terminate completely, and the share for any remaining Primary or Contingent Beneficiary shall be increased on a pro rate basis. If no Primary or Contingent Beneficiary survives me, the remaining balance in the account shall be distributed in accordance with the plan provisions to my estate. I hereby revoke an prior beneficiary designation made by me and designate the below as my Primary and Contingent Beneficiary of this IRA.
Primary
Contingent
Name:
Relationship:
Address:
City:
State:
Zip:
Social Security Number:
Date of Birth: (MM/DD/YYYY)
Share:
Primary
Contingent
Name:
Relationship:
Address:
City:
State:
Zip:
Social Security Number:
Date of Birth: (MM/DD/YYYY)
Share:
Primary
Contingent
Name:
Relationship:
Address:
City:
State:
Zip:
Social Security Number:
Date of Birth: (MM/DD/YYYY)
Share:

Your Signature (Parent or Custodian)
Printed Name:
Signature: _______________________________________________ Date:

Your Signature (Child or Recepient)
Printed Name:
Signature: _______________________________________________ Date: