APPOINTMENT OR CHANGE OF BENEFICIARY DESIGNATION REQUEST

Account Title: Account #
     
     

If two or more persons create such an account, they own the account jointly with rights of survivorship. Beneficiaries cannot withdraw unless: (1) all persons creating the account are deceased, and (2) the beneficiary is then living. If two or more beneficiaries are named and survive the death of all persons creating the account, such beneficiaries will own this account in equal shares, unless indicated otherwise without right of survivorship. The persons creating this account reserve the right to: (1) change beneficiaries, or allocation (2) change account type, and (3) withdraw all or part of the account funds at any time.

BENEFICIARIES

 
Name 1: Name 2:
Address: Address:
   
Tel. No.: Tel. No.:
Social Security #: Social Security #:
Date of Birth: Date of Birth:
Relationship to Owner: Relationship to Owner:
Percentage: Percentage:

Name 3: Name 4:
Address: Address:
   
Tel. No.: Tel. No.:
Social Security #: Social Security #:
Date of Birth: Date of Birth:
Relationship to Owner: Relationship to Owner:
Percentage: Percentage:


Signature of Account Owner
Date
Signature of Account Owner
Date

All account owners must sign this Change of Beneficiary Designation Request. Original Certificate of Deposit must be returned prior to issuance of a new Certificate of Deposit with the new beneficiary designation.

FOR BANK USE ONLY

Signature verified by: Date:
Processed by: Date:
Approved by: Date: