Beneficiary Designation Form (PDF) - IAM National Pension Fund

DO NOT USE THIS FORM IF YOU ARE CURRENTLY RECEIVING BENEFITS FROM THE FUNDCONTACT THE FUND OFFICE FOR THE CORRECT FORMI.A.M. NATIONAL PENSION FUNDDesignation of Beneficiary Form for Preretirement Death Benefits(other than the 50% Spouse Preretirement Death Benefit).Covered Employee: __________________________________________________________________Last NameFirst NameSocial Security Number: ___ ___ ___- ___ ___- ___ ___ ___ ___ Date of Birth: __ __/__ __/___ ___Current Address: ____________________________________________________________________City: _________________________________State: __________________ Zip: _______________If you need more space to designate either primary or successor beneficiaries, attach to this form aseparate sheet of paper containing the same information requested below.I designate the following individual(s) as my primary beneficiary or beneficiaries:(1) Primary Beneficiary:____________________________________________________________Last NameFirst NameSocial Security Number: ___ ___ ___- _____ _____ - ______ _____ _____ _____Relationship of Beneficiary: ___________________________________________________________Address of Beneficiary: ______________________________________________________________City: _________________________________ State: ___________________Zip: ____________(2) Primary Beneficiary: ___________________________________________________________Last NameFirst NameSocial Security Number: ___ ____ ____- _____ _____- _____ ______ _____ _____Relationship of Beneficiary: ___________________________________________________________Address of Beneficiary: ______________________________________________________________City: _________________________________ State: __________________Zip: _____________(3) Primary Beneficiary: ____________________________________________________________Last NameFirst NameSocial Security Number: ___ ___ ___-____ ____- ____ _____ ____ _____Relationship of Beneficiary: ___________________________________________________________Address of Beneficiary: _______________________________________________________________City: _________________________________ State: ____________________ Zip: ______________

I hereby designate the following individual(s) as my successor beneficiary or beneficiaries:Successor Beneficiary: ___________________________________________________Last NameFirst NameSocial Security Number: ____ ____ ____- ____ ____- ____ _____ _____ _______Relationship of Beneficiary: ___________________________________________________________Address of Benefic iary: _______________________________________________________________City:__________________________________ State: ____________________ Zip: _____________Successor Beneficiary: ______________________________________________________Last NameFirst NameSocial Security Number: ____ _____ ____- _____ _____- ______ ______ _____ ______Relationship of Beneficiary: __________________________________________________________Address of Beneficiary: ______________________________________________________________City: _________________________________ State: _____________________ Zip: ____________Successor Beneficiary: ______________________________________________________Last NameFirst NameSocial Security Number: ___ ____ ____- ____ _____- _____ _____ _____ ______Relationship of Beneficiary: ___________________________________________________________Address of Beneficiary: _______________________________________________________________City: _________________________________ State: _____________________ Zip: _____________Date: _______________________Signature: ____________________________________If more than one person is named as your primary or successor beneficiary, any benefits to which thedesignated beneficiaries are entitled will be divided equally.This form revokes any prior designations and will be revoked by any later designations made duringyour lifetime.Please complete, sign and mail in an envelope to:I.A.M. National Pension Fund1300 Connecticut Avenue N.W.Suite 300Washington D.C. 20036-1711