Beneficiary Designation Governmental 457(b) Plan

Beneficiary DesignationGovernmental 457(b) PlanUse black or blue ink when completing this form. For questions regarding this form, contact Service Provider at 1-888-733-2748.98965-01 City & County of San Francisco 457 Deferred Compensation PlanA Participant InformationAccount extension identifies funds transferred to abeneficiary due to death, alternate payee due to divorceor a participant with multiple accounts.Social Security NumberAccount Extension/ /Last Name First Name M.I. Date of Birth( )Street AddressPersonal Phone Number( )City State Zip Code Work Phone NumberEmail Address❑ Married ❑ UnmarriedDivision/Payroll CenterB Primary Beneficiary Designation (Attach an additional sheet to name additional beneficiaries.)Please If I am read married, Participant my Plan Consent requires section my spouse prior as to completing primary beneficiary the Beneficiary for at least Designation 50% or my section. spouse consents to my beneficiary designation.%% of Account Balance Primary Beneficiary Name Relationship Social Security NumberStreet Address City State Zip Code%% of Account Balance Primary Beneficiary Name Relationship Social Security NumberStreet Address City State Zip Code%% of Account Balance Primary Beneficiary Name Relationship Social Security NumberStreet Address City State Zip CodeContingent Beneficiary Designation%% of Account Balance Contingent Beneficiary Name Relationship Social Security NumberStreet Address City State Zip Code%% of Account Balance Contingent Beneficiary Name Relationship Social Security NumberStreet Address City State Zip Code%% of Account Balance Contingent Beneficiary Name Relationship Social Security NumberCStreet Address City State Zip CodeSignature and ConsentParticipant ConsentThis designation is effective upon execution and delivery to Service Provider at the address below. If I name more than one beneficiary in eithercategory, the surviving beneficiaries in that category will share equally unless otherwise indicated. I have the right to change the beneficiary. Ifany information is missing, additional information may be required prior to recording my beneficiary designation. If my primary and contingentbeneficiaries predecease me or I fail to designate beneficiaries, amounts will be paid pursuant to the terms of the Plan Document or applicable statelaw.This designation supersedes all prior designations. Beneficiaries will share equally if percentages are not provided and any amountsunpaid upon death will be divided equally. Primary and contingent beneficiaries must separately total 100.00%. The number of primaryor contingent beneficiaries I may name is not limited. An additional sheet may be attached, if necessary.,STD ,FBENED ,05/16/13 ,Page 1 of 2JN/Manual (SR 271491)][B01:010713][JNEW/322903275

98965-01Last Name First Name M.I. Social Security Number NumberA spouse or registered domestic partner is automatically the primary beneficiary of an employee’s retirement plan death benefits. If I am marriedor in a registered domestic partnership, and designate a primary beneficiary in addition to or other than my spouse or registered domestic partnerfor 50% or more of the account balance, my spouse or registered domestic partner must consent by signing below and in the presence of a notaryor plan representative. If I am not married or in a registered domestic partnership now, but become married or enter into a registered domesticpartnership in the future, my spouse or registered domestic partner may be entitled to interest in this account from the time of marriage or registrationregardless of my beneficiary designation. Designated beneficiaries other than my spouse or registered domestic partner will be entitled to theremainder of the death benefit account as I direct.I understand that Service Provider is required to comply with the regulations and requirements of the Office of Foreign Assets Control, Departmentof the Treasury (“OFAC”). As a result, Service Provider cannot conduct business with persons in a blocked country or any person designated byOFAC as a specially designated national or blocked person. For more information, please access the OFAC Web site at:http://www.treasury.gov/about/organizational-structure/offices/Pages/Office-of-Foreign-Assets-Control.aspx.Any Participant person Signature who presents false or fraudulent information is subject to criminal and Date civil (Required) penalties.Participant SignatureSpousal Consent (Spouse also refers to a Registered Domestic Partner)Dates of the participant’s spouse signature and notarization must much match.Spouse SignatureDate (Required) yI, (name of spouse) , the current spouse of the participant, hereby voluntarilyconsent to the participant’s primary beneficiary designation above above and understand understand its effect. its I effect. understand I understand that my spouse’s that my beneficiary spouse’s designation beneficiarymeans designation that I will means not receive that I will at least not receive 50% of at his least or her 100% vested of his account or her balance vested under account the balance Plan and under that my the spouse’s Plan and election that my is not spouse’s valid unless election I consent is notto valid it. I unless understand I consent that by to it. consenting I understand to the that beneficiary by consenting designation, to the I give beneficiary up my right designation, to a qualified I give survivor up my right annuity. to a I hereby qualified voluntarily survivor consent annuity. to Ithe hereby primary voluntarily beneficiary(ies) consent named to the primary on the previous beneficiary(ies) page. I understand named on that the previous my consent page. is irrevocable I understand unless that my my spouse consent revokes is irrevocable the waiver unless election, mychanges spouse revokes the beneficiary the waiver designation, election, or changes designates the beneficiary me to receive designation, least 50% or of designates his or her me vested to receive account at balance. least 100% of his or her vested accountbalance.Witness of Spouse’s SignatureThe spouse’s signature must be witnessed by a Notary Public.Date (Required)Statement of NotaryNOTE: Notary seal must be visible.State of ) The consent to this request was subscribed and sworn (or affirmed)to before me on this day of , year ,by)ss. (name of spouse)proved to me on the basis of satisfactory evidence to be the person whoCounty of ) appeared before me, who affirmed that such consent represents his/her freeand voluntary act.SEALNotary Public SignatureMy commission expires-OR-Statement of Plan AdministratorI certify that the participant’s spouse (or registered domestic partner) signed the Spousal Consent section in my presence.Plan Representative SignatureDateDMailing InstructionsParticipant forward to Service ProviderGreat-West Retirement Services ®Regular Mail:PO Box 173764Denver, CO 80217-3764Phone: 1-888-733-2748Fax: 1-866-745-5766Website: www.sfdcp.orgExpress Mail:8515 E. Orchard RoadGreenwood Village, CO 80111Great-West Financial SM refers to products and services provided by Great-West Life & Annuity Insurance Company; Great-West Life & Annuity InsuranceCompany of New York, White Plains, New York; their subsidiaries and affiliates. Great-West Retirement Services ® refers to products and services provided byGreat-West Life & Annuity Insurance Company, FASCore, LLC (FASCore Administrators, LLC in California), Great-West Life & Annuity Insurance Company ofNew York, White Plains, New York, and their subsidiaries and affiliates. Great-West Life & Annuity Insurance Company is not licensed to conduct business inNew York. Insurance products and related services are sold in New York by its subsidiary, Great-West Life & Annuity Insurance Company of New York. Otherproducts and services may be sold in New York by FASCore, LLC.,STD ,FBENED ,05/16/13 ,Page 2 of 2JN/Manual (SR 271491)][B01:010713][JNEW/322903275