PNNL Pension Plan

Beneficiary Designation and Spousal/

Registered Partner Consent
As a participant in the Pension Plan of the Pacific Northwest Laboratories, Battelle Memorial Institute (the
“Plan”), you may designate a beneficiary to receive pre-retirement death benefits from the Plan if you die after
you are vested and before your benefits start. Use this form to choose your beneficiaries for the first time,
to change your beneficiaries or to change your beneficiary percentages. After you enter all your beneficiary
information below, please sign and date the form before returning it. Be sure to keep a copy for your records.

About You, the Participant

Brian S. Minsk
Full Name Social Security Number

Street Address/ Apt Number

City State Zip Code

Section I - Choose Your Beneficiary

Provide the percentage of the benefit you wish each beneficiary to receive (must total 100%). Fill in the
requested information (*required fields). Some examples of relationships are: spouse, registered partner, child,
stepchild, parent, trust or estate.

If you are legally married or have a registered partner and you wish to designate a beneficiary other
than your spouse or registered partner for any pre-retirement death benefits, your spouse or registered
partner MUST consent to the designation by completing the Spousal/Registered Partner Consent
in Section II of this form. If your spouse or registered partner does not sign the Spousal/Registered
Partner Consent, witnessed by a notary public, your beneficiary designation will be invalid.

If you are legally married or have a registered partner and you designate a beneficiary other than
your spouse or registered partner prior to the July 1 preceding your 35th birthday, the beneficiary
designation will expire on that date and your spouse or registered partner will automatically become
your designated beneficiary unless and until a subsequent beneficiary designation is submitted, along
with the Spousal/Registered Partner Consent form, if applicable.

If you die before your benefits start and you do not have a designated beneficiary on file or your designated
beneficiary does not survive you, the Plan provides that a pre-retirement death benefit will be paid to the first of
the following individuals who survive you:
● Spouse or Registered Partner
● Children and issue of deceased children (including adopted children)
● Surviving parents
● Surviving brothers and sisters, or
● Your estate

If your beneficiary is a minor when a preretirement death benefit commences, the payment will be made to the
legal guardian of the minor.

If you name a trust as a beneficiary you must provide the full name of the trust and the name of the trustee.
The Plan may impose a limit on the numer of beneficiaries under the trust.

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PNNL Pension Plan
Beneficiary Designation and Spousal/
Registered Partner Consent
Beneficiary Designation
I name the following primary beneficiary(ies), revoking any prior designation of beneficiaries, to receive my
preretirement benefits under the Plan.

If more than one primary beneficiary is named and at least one of them is living on the date of my death, the
percentage of the Plan benefit that had been designated to the beneficiaries who do not survive me will be
divided equally among my surviving primary beneficiary(ies).
[If you want to name additional primary or secondary beneficiaries, please attach a separate sheet.]

*Primary Beneficiary Name *Percentage

*Relationship *Date of Birth (MM/DD/YYYY) *Social Security Number

Street Address

City State Zip Code

* Required fields.

*Primary Beneficiary Name *Percentage

*Relationship *Date of Birth (MM/DD/YYYY) *Social Security Number

Street Address

City State Zip Code

* Required fields.

*Primary Beneficiary Name *Percentage

*Relationship *Date of Birth (MM/DD/YYYY) *Social Security Number

Street Address

City State Zip Code

* Required fields.

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PNNL Pension Plan
Beneficiary Designation and Spousal/
Registered Partner Consent

*Primary Beneficiary Name *Percentage

*Relationship *Date of Birth (MM/DD/YYYY) *Social Security Number

Street Address

City State Zip Code

* Required fields.

*Primary Beneficiary Name *Percentage

*Relationship *Date of Birth (MM/DD/YYYY) *Social Security Number

Street Address

City State Zip Code

* Required fields.

Trust as primary beneficiary

Complete this section if you would like to name a trust as a primary beneficiary.
NOTE: The tax ID for the Trust and other documentation will be required prior to processing any
payments to the Trust.

*Trust name *Percentage

*Trustee

Street Address

City State Zip Code

* Required fields.

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PNNL Pension Plan
Beneficiary Designation and Spousal/
Registered Partner Consent
If none of my primary beneficiaries are living on the date of my death, make payment to the following
secondary beneficiary(ies). If more than one secondary beneficiary is named and at least one of them is living
on the date of my death, the percentage of the Plan benefit that had been designated to the beneficiaries who
do not survive me will be divided equally among my surviving secondary beneficiary(ies).

*Secondary Beneficiary Name *Percentage

*Relationship *Date of Birth (MM/DD/YYYY) *Social Security Number

Street Address

City State Zip Code

* Required fields.

*Secondary Beneficiary Name *Percentage

*Relationship *Date of Birth (MM/DD/YYYY) *Social Security Number

Street Address

City State Zip Code

* Required fields.

*Secondary Beneficiary Name *Percentage

*Relationship *Date of Birth (MM/DD/YYYY) *Social Security Number

Street Address

City State Zip Code

* Required fields.

*Secondary Beneficiary Name *Percentage

*Relationship *Date of Birth (MM/DD/YYYY) *Social Security Number

Street Address

City State Zip Code

* Required fields.

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PNNL Pension Plan
Beneficiary Designation and Spousal/
Registered Partner Consent

*Secondary Beneficiary Name *Percentage

*Relationship *Date of Birth (MM/DD/YYYY) *Social Security Number

Street Address

City State Zip Code

* Required fields.

Trust as secondary beneficiary

Complete this section if you would like to name a trust as a secondary beneficiary.
NOTE: The tax ID for the Trust and other documentation will be required prior to processing any
payments to the Trust.

*Trust name *Percentage

*Trustee

Street Address

City State Zip Code

* Required fields.

Once you make this beneficiary designation, it will be effective as of the date it is received by the Battelle
Pension Service Center and generally will remain effective until the Battelle Pension Service Center receives a
new beneficiary designation form or payment of your benefits start.

This beneficiary form replaces any earlier beneficiary designation that you may have made.

Please check here if you have attached an additional sheet of beneficiaries.

*Participant Signature *Date

* Required fields.

NOTE: Section II – Spousal/Registered Partner Consent on next page

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PNNL Pension Plan
Beneficiary Designation and Spousal/
Registered Partner Consent
TO PARTICIPANT: If you are legally married or have a registered partner and you wish to designate
a primary beneficiary other than your spouse or registered partner for any pre-retirement death
benefits, your spouse or registered partner MUST consent to the designation by completing this
Spousal/Registered Partner Consent. If your spouse or registered partner does not sign this Consent,
witnessed by a notary public, your beneficiary designation will be invalid.

Section II - Statement of Spousal/Registered Partner Consent

● I certify that I am the spouse or registered partner of ________________________________________,

a participant in the Pension Plan of the Pacific Northwest Laboratories, Battelle Memorial Institute (the
"Plan"). I understand that, should my spouse or registered partner die prior to commencing pension
payments, I have the right to receive my spouse’s or registered partner’s pre-retirement death benefits.
I hereby agree to give up that right. I understand that as a result of signing this Spousal/Registered
Partner Consent, I will not receive the pre-retirement death benefit as provided by the Plan after my
spouse or registered partner dies.
● I understand that, as a result of my signing this Spousal/Registered Partner Consent, I am consenting
to the beneficiary(ies) designated by my spouse or registered partner. I understand that this Spousal/
Registered Partner Consent applies only to the beneficiary(ies) designated in Section I of this form.
A new Spousal/Registered Partner Consent form is required if my spouse or registered partner later
submits a new beneficiary designation.
● I understand that I do not have to give this Spousal/Registered Partner Consent, and I am signing this
form voluntarily. I understand that if I do not sign this Spousal/Registered Partner Consent, my spouse
or registered partner will not be able to designate someone other than me as the primary beneficiary for
any pre-retirement death benefits.
● A notary public must witness my signature. I should not sign this form until I am in the presence of a
notary public.

Spouse’s or Registered Spouse’s or Registered Date

Partner’s Name (Please Print) Partner’s Signature

Witness to Consenting Spouse’s or Registered Partner’s Signature

STATE: COUNTY:

On the ____day of ___________________, 20____, before me personally appeared

_______________________________________________________________________, to me known to
be the individual described in and who executed the foregoing document, and proved to me on the basis
evidence/documentation and she/he acknowledged to me that she/he executed the same.

NOTARY SEAL NOTARY PUBLIC MY COMMISSION EXPIRES

(Ink Preferred)

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PNNL Pension Plan
Beneficiary Designation and Spousal/
Registered Partner Consent
Return to: Battelle Pension Service Center
PO Box 9920
Providence, RI 02940-4020

For more information, visit www.myplansconnect.com/battelle. If you have questions, please contact the
Battelle Pension Service Center. Representatives are available via Live Chat at www.myplansconnect.com/
battelle or by phone at 800-752-6573 Monday through Friday from 9:00 AM to 8:00 PM Eastern Time.

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