Beneficiary Designation 401(k) Plan - Empower …

Beneficiary Designation401(k) PlanSTD FBENED ][05/26/17)(98960-01 CHG NUPARTNO_GRPG 424/][GU22)(/][MBNDDOC ID: 483766008)(Page 1 of 4 Texa$aver 401(k) Plan98960-01 For My Information For questions regarding this form, visit the website at or contact Service Provider at 1-800-634-5091. Use black or blue ink when completing this InformationAccount extension, if applicable, identifies fundstransferred to a Beneficiary due to participant'sdeath, alternate payee due to divorce or aparticipant with multiple ExtensionSocial Security Number (Must provide all 9 digits)Last NameFirst AddressMarriedUnmarried//Date of Birth( )Daytime Phone Number( )Alternate Phone NumberBBeneficiary Designation (Attach an additional sheet to name additional beneficiaries.)

STD FBENED ][05/26/17)(98960-01 CHG NUPARTNO_GRPG 424/][GU22][MBNDDOC ID: 483766008)(Page 3 of 4 This page is for informational purposes only - Do not return with the Beneficiary Designation form

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