Beneficiary Designation Form - Citibank

Beneficiary Designation FormPart I: Add/ change Beneficiary DesignationDate:_____Branch:_____To: Citibank , Customer Service Center The undersigned is (are) the owner(s) of: _____List all account numbers onwhichyou want to add/ change Beneficiary (ies)Entitled _____Name(s) of Account Holder(s)_____Name(s) of current Beneficiary (ies)(if applicable) in trust for_____Effective this date:I/(We) revoke, if applicable, the existing Beneficiary (ies) Designation (s) listed above. I/(We) direct you to change the title of the above listed accounts to the following:_____ Name(s) of Account Holder(s) must not changeIn Trust For:1. _____Name of new Beneficiary _____CitizenshipDate of Birth: mm/dd/yyyy Relation to Primary Account Holder _____Permanent Address2. _____Name of new Beneficiary _____CitizenshipDate of Birth: mm/dd/yyyy Relation to Primary Account Holder _____Permanent Address1 BEFRQFME0710 Authentication of SignatureThis form can be acknowledged one of three ways; either before (1) a Notary or, (2) if signed outside of the , by a consul or Vice-Consul or any official authorized to take acknowledgments and then submitted to a Consul or Vice-Consul for validation or (3) be signedand verified before a Citibank ValidationPerformed by: a Notary (if signed in the United States or Puerto Rico) ss:STATE OF _____COUNTY OF_____On this_____day of_____, 20_____before me,_____personally appeared, personally know

Beneficiary Designation Form Part I: Add/Change Beneficiary Designation Date:_____ Branch:_____

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