Beneficiary Designation Form Instructions

Direct Account Plan #385086-01

All information must be typed or printed neatly, using uppercase letters and blue or black ink. If it is necessary to make corrections
to the beneficiary section, you must place your initials next to the corrected or crossed-out words. Do not use correction fluid or
correction tape; otherwise, the form will be returned to you. If you have any questions about completing this form or you need additional
forms, log on to www.DAP401k.com or call Participant Service Center at 1-844-861-4DAP (4327).

A. Participant Information
Complete all information, and check either Married or Unmarried.
B. Beneficiary Designation
A beneficiary can be a spouse, non-spouse or nonperson, such as a trust, named by you, the participant, to receive payment of
benefits provided under the named plan in the event of your death.
• If these sections are not filled out completely, the form will be returned to you.
• The beneficiary designation should not include wording such as “either/or” or “and/or”
• The percentages must be in whole-number percents. (Example: 33%)
If you are married, your spouse must be the primary beneficiary of at least 50% of your account unless your spouse consents to a
lower percentage.
Naming multiple beneficiaries: If you want to name more than three primary or three contingent beneficiaries, you may attach
additional sheet(s).
Naming an estate as beneficiary: Please consult your attorney for advice on the effect of this designation. No additional legal
documentation is required at this time.
Naming a trust as beneficiary: Provide the name, date and tax identification number assigned to the trust (if available). See example
3 on page 2. Please consult your attorney for advice on the effect of this designation. Do not send a copy of the trust agreement
at this time.
C. Signatures and Consent
By signing and dating this section, you officially designate the person(s) listed on the form as your primary beneficiary(ies) and, if
applicable, your contingent beneficiary(ies) for this Plan. Your beneficiary designation will not be valid unless this form is on file with
the recordkeeper for the Plan at the time of your death.
Your Spouse’s Consent: If you are married and you wish to name a primary beneficiary other than your spouse to receive more than
50% of your benefit, your spouse must sign his or her consent to that election in the presence of a Notary Public. A bank, law office or
local governmental office will typically have a Notary Public on staff. If your spouse does not waive his or her right to benefits in excess
of 50%, then your spouse will automatically be the primary beneficiary of at least 50% of your account.
D. Mailing Instructions
Once the form is completed and signed, make a copy of pages 3 and 4 of this form for your files and return the original to the following
address:
Empower Retirement
PO Box 173764
Denver, CO 80217-3764
Fax: 1-866-633-5212

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 EXAMPLE BENEFICIARY DESIGNATIONS
Example 1: One Beneficiary
B Benefi
Bene
eneficiary Designatio
enefi Designation (Attach
(Atta
tta
ta an additional sheet to name additional beneficiaries.)
Ex Primary
P rimary
ary Beneficiary Designatio
Designation
on (Primary beneficiary designations must total 100%.)
• If I am married, my Plan requires m
my spouse to be named as primary beneficiary for at least 50% of my account balance, or my spouse must
consent
onsent to my beneficiary
ci design
desig
designation.
100 % John M. Doe Spouse 111-222-3333 01 / 06 /1954
% of Account
Accou Balance Prima
Prim
Primary Beneficiary Name Relationship Social Security Number Date of Birth
150
50
0 Main Street
S Anytown MO 60000
Streett Address City State Zip Code
44-
44-4
4
(123) 444-4444 John.M.Doe@abc.com
Phone Number
mber
ber Email
Em Address

ple 2: Two
Example o Beneficiaries in Unequal
Unequa Shares
B Beneficiary Designation
ation
a (Attach an additional sheet to name additional beneficiaries.)
(A

Primary Beneficiary
ry Des
Desi
Designation (Primary
mary
ary benefic
ci
ciary designations must total 100%.)

• If I am married,
rried, my Plan
an requires
uires my spouse
spo se to
spou o be named
nam as prim
primary beneficiary for at least 50% of my account balance, or my spouse must
consent to my beneficiary
ar de
designation.
esignation.
es
am
75 % Ann
A
Anne
n D
ne Doe
e S
Sister 333-44-5555 04 / 22 /1951
% of Account Balance
nce Primary
ry Beneficiary
ci
cia Name Relationship
Relat Social Security Number Date of Birth
32 Main Street A
An
Anytownn MO 60000
Street Address City
y State Zip Code
(123) 555-5555 Anne
Anne.Doe@ab
@abc
abc.com
abc
Anne.Doe@abc.com
Phone Number Email
Em Address
Addre
dres
ress
res
25 % Mi h l Doe
Michael Doee B
Br
Brother
rother
th 999-88-7777 05 / 15 /1958
% of Account Balance Primary
mary Benefi
ficiary
ciary Nam
Name Relationship
Rela
ationship
a
at Social Security Number Date of Birth
46 Any Street Anytownwn
n CA 90000
Street Address City
ty
y State Zip Code
(123) 666-6666 oe@abc.com
e@abc.com
Michael.Doe@abc.com
Phone Number Email
mail Address
sss

Example 3: Trust as Beneficiary

B Beneficiary Designation (Attach an additional sheet to name
e additiona
additional beneficiaries.)
iarie
aries.)
arie

Primary Beneficiary Designation (Primary beneficiary designations m

must
ust
ust total 100%.)
0%.)
pl
• If I am married, my Plan requires my spouse to be named as primary
imary
mary beneficiary for at leas
least 50% of my account balance, or my spouse must
consent to my beneficiary designation.
100 % Trust of Jane Doe Trust 11
11-2234567
223
2234 / /
% of Account Balance Primary Beneficiary Name Relationship
hip Social Security
S Number
Num Date of Birth
451 Main Street Anytown M
MO 60000
Street Address City te
Statee Zip Code
(123) 777-7777 Jane.Doe@abc.com
Phone Number Email Address
es

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Manual SR 2982930
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Example 4: Three
ree
ee Benefic
ciaries
Benefi
ficiary
ficiary
cia Designa
Designation (Attach an additional sheet to name additional beneficiaries.)
(A

Primary Beneficiary Designat

Primary Designation (Primary beneficiary designations must total 100%.)
Designa
Ex • If I am
m married, my Plan requires
re m
my spouse to be named as primary beneficiary for at least 50% of my account balance, or my spouse must
consent
onsent to my beneficiary designatio
designati
designation.
o
34 % Anne Doe Sister 333-44-5555 04 / 22 /1951
% of Account Balance Primary Bene
Beneficiary Name Relationship Social Security Number Date of Birth
32 Main Street Anytown MO 60000
Street
eet Addre
Address City State Zip Code
(123) 555-5555 Anne.Doe@abc.com
Phone Number
Numb
Numbe Email Addre
Address
33 % Larry Doe Brother 999-88-7777 05 / 15 /1958
% of Accountt Balance
B Primary Benefi
efi
ficiary
c Name Relationship Social Security Number Date of Birth
46 Any Street Anytown CA 90000
Street
et Address City State Zip Code
(123) 888-8888 Larry.Doe@abc.com
Phone Number
umber Email
ail Address
33 % Harry Doe Brother 999-888-6666 05 / 15 /1958
% of Account Balance Primary Beneficiary
Primary c Name
ame Relationship Social Security Number Date of Birth
am
1636 Any Street Anytown CO 80000
Street Address City State Zip Code
(123) 999-9999 Harry.Doe@abc.com
Phone Number Email Address
Addres
Addre
pl
es

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 Beneficiary Designation
401(k) Plan
Directed Account Plan 385086-01
For My Information
• For questions regarding this form, visit the website at www.DAP401k.com or contact Service Provider at 1-844-861-4DAP
1-844-861-4327. (4327).
• Use black or blue ink when completing this form.
A Participant Information

Account extension, if applicable, identifies funds

transferred to a beneficiary due to participant's - -
death, alternate payee due to divorce or a
participant with multiple accounts.
Account Extension Social Security Number (Must provide all 9 digits)
/ /
Last Name First Name M.I. Date of Birth
( )
Email Address Daytime Phone Number

Married Unmarried ( )
Alternate Phone Number

B Beneficiary Designation (Attach an additional sheet to name additional beneficiaries.)

Primary Benefi
Primary Beneficiary Designation ((Primary
ciary Designation beneficiary
Primary benefi designations must
ciary designations must total
total 100%
100%.)- percentage can be made out to two decimal places.)

•● IfIfI Iam
ammarried,
married,my
myPlan
Planrequires
requiresmy
myspouse
spouseto tobe
be named
named as as primary
primary benefi ciary for
beneficiary for at
at least
least 50%
50% of
of my
my account
account balance, or my
balance, or my spouse
spouse must
must
consent
consenttotomymybenefi ciary designation.
beneficiary designation.
● See the attached examples on how to complete the below beneficiary designations if the beneficiary is a non-individual, such as a trust, charity
1. or estate. % / /
% of Account % Balance Primary Beneficiary Name Relationship Social Security Number Date /of Birth
/
% of Account Balance Primary Beneficiary Name Relationship Social Security or Taxpayer Date of Birth
(Name of Individual, Trust, Charity, etc.) Identification Number or Trust Date
Street Address City State Zip Code
Street Address City State Zip Code
( )
Phone Number Email Address
Phone Number (Optional)
2. %
% /
/
//
% of Account Balance
% of Account Balance
Primary Beneficiary NameRelationship
Primary Beneficiary Name
Relationship Social Security Number
Social Security or Taxpayer
Date of Birth
Date of Birth
(Name of Individual, Trust, Charity, etc.) Identification Number or Trust Date
Street Address City State Zip Code
Street Address City State Zip Code
( )
Phone
Phone Number
Number (Optional) Email Address
3. % % // //
%
% of
of Account
Account Balance
Balance Primary
Primary Benefi
Beneficiary ciary
Name NameRelationship
Relationship Social
Social Security
Security Number
or Taxpayer Date
Dateofof
Birth
Birth
(Name of Individual, Trust, Charity, etc.) Identification Number or Trust Date

Street Address City State Zip Code

Street Address City State Zip Code
( )
Phone Number
Phone Number (Optional) Email Address

Contingent Benefi
Contingent Beneficiary Designation ((Contingent
ciary Designation beneficiary
Contingent benefi designations must
ciary designations must total
total 100%
100%.)- percentage can be made out to two decimal places.)

1. % % // //
% of
% of Account
Account Balance
Balance Contingent Beneficiary
Contingent Name Name Relationship
Beneficiary Relationship Social Security
Social or Taxpayer
Security Number Date
Date ofof Birth
Birth
(Name of Individual, Trust, Charity, etc.) Identification Number or Trust Date

Street Address City State Zip Code

Street Address City State Zip Code
( )
Phone
Phone Number
Number (Optional) Email Address

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 385086-01
Last Name First Name M.I. Social Security Number Number

B Beneficiary Designation (Attach an additional sheet to name additional beneficiaries.)

Contingent
Contingent Beneficiary
Beneficiary Designation
Designation (Contingent
(Contingent beneficiary
beneficiary designations
designations must
must total
total 100%
100%.)- percentage can be made out to two decimal places.)

2. % % / / //
% of Account Balance Contingent Beneficiary Name
% of Account Balance Contingent Beneficiary Name Relationship
(Name of Individual, Trust, Charity, etc.)
Relationship
Social Security or Taxpayer
Social Security
Identification Number
Number
Date of Birth
Date of Birth
or Trust Date

StreetAddress
Street Address City
City State
State ZipZip
CodeCode
( )
Phone Number (Optional)
Phone Number Email Address
% / /
3. %
% of Account Balance Contingent Beneficiary Name Relationship Social Security or Taxpayer / of/ Birth
Date
% of Account Balance Contingent Benefi
(Name of Individual, Trust,ciary
Charity,Name
etc.) Relationship Identification Number
Social Security Number or Trust
Date Date
of Birth

Street Address City State Zip Code

Street
( Address
) City State Zip Code
Phone Number (Optional)
Phone Number
Phone Number (Optional) Email Address

C Signatures and Consent (Signatures must be on the lines provided.)

Participant Consent for Beneficiary Designation (Please sign on the 'Participant Signature' line below.)

I have completed, understand and agree to all pages of this Beneficiary Designation form. Subject to and in accordance with the terms of the
Plan, I am making the above beneficiary designations for my vested account in the event of my death. If I have more than one primary beneficiary,
the account will be divided as specified. If a primary beneficiary predeceases me, his or her benefit will be allocated to the surviving primary
beneficiaries. Contingent beneficiaries will receive a benefit only if there is no surviving primary beneficiary, as specified. If a contingent beneficiary
predeceases me, his or her benefit will be allocated to the surviving contingent beneficiaries. If I fail to designate beneficiaries, amounts will be paid
pursuant to the terms of the Plan or applicable law. This designation is effective upon execution and delivery to Service Provider. If any information
is missing, additional information may be required prior to recording my designation.
This designation supersedes all prior designations. Beneficiaries
Beneficiaries will share equally if percentages are not provided and any amounts unpaid upon
death will be divided equally. Primary and contingent beneficiaries
beneficiaries must separately total 100%.100% in The percentages
whole can be divided up to two
percentages.
d i l i that t (EServicel Provider
33 33%)
I understand is required to comply with the regulations and requirements of the Office of Foreign Assets Control, Department
of the Treasury ("OFAC"). As a result, Service Provider cannot conduct business with persons in a blocked country or any person designated by
OFAC as a specially designated national or blocked person. For more information, please access the OFAC website at: http://www.treasury.gov/
about/organizational-structure/offices/Pages/Office-of-Foreign-Assets-Control.aspx.
Important Notice: In accordance with ERISA and/or Plan Document, if I am married and I elect a primary beneficiary other than my spouse or in
addition to my spouse, my spouse must consent by signing the Spousal Consent for Beneficiary Designation section of this form.

Any person who presents a false or fraudulent claim is subject to criminal and civil penalties.

Participant Signature Date (Required)

A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.

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 385086-01
Last Name First Name M.I. Social Security Number Number

C Signatures and Consent (Signatures must be on the lines provided.)

Spousal Consent for Beneficiary Designation (If applicable, please have the Spouse sign on the 'Spouse's Signature' line below.)

I, (name of spouse) _______________________________, the participant's current spouse, voluntarily consent to the Beneficiary(ies) designated
on this form and acknowledge that all amounts payable under the Plan by reason of the participant's death will be payable pursuant to such
designation. I understand the designation of anyone other than me as Primary Beneficiary of any benefits payable after the participant's death are
ineffective unless I consent, and that by signing below, I give up my rights to benefits that I may otherwise have under law (QPSA). I understand
that my spouse does not need my consent to any non-spouse beneficiary designation for the non-QPSA portion, if any, of the death benefit.

Spouse's Signature Date (Required)

A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.

For Residents of all states (except California), please have your notary complete the section below.
Notice to California Notaries using the California Affidavit and Jurat Form the following items must be completed by the notary on the state
notary form: the title of the form, the plan name, the plan number, the document date, my name and my spouse’s name. The notary forms not
containing this information will be rejected and it will delay this request.
My signature must be notarized by a Notary Public. The date I sign this form in the ‘My Consent’ section must match the date on which my signature
is notarized in this section.

Statement of Notary NOTE: Notary seal must be visible.

The consent to this request was subscribed and sworn (or affirmed)
State of ) to before me on this day of , year , by
SEAL
)ss. (name of spouse)
proved to me on the basis of satisfactory evidence to be the person
County of ) who appeared before me, who affirmed that such consent represents
his/her free and voluntary act.

Notary Public My commission expires / /

A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.

D Mailing Instructions

After all signatures have been obtained, this form can be sent by
Fax to: OR Regular Mail to: OR Express Mail to:
Empower Retirement Empower Retirement Empower Retirement
1-866-633-5212 PO Box 173764 8515 E. Orchard Road
Denver, CO 80217-3764 Greenwood Village, CO 80111

Core securities, when offered, are offered through GWFS Equities, Inc. and/or other broker dealers.
GWFS Equities, Inc., Member FINRA/SIPC, is a wholly owned subsidiary of Great-West Life & Annuity Insurance Company.
Empower Retirement refers to the products and services offered in the retirement markets by Great-West Life & Annuity Insurance Company, Corporate
Headquarters: Greenwood Village, CO; Great-West Life & Annuity Insurance Company of New York, Home Office: NY, NY; and their subsidiaries and
affiliates. The trademarks, logos, service marks, and design elements used are owned by their respective owners and are used by permission.

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