Beneficiary Designation 401(k) Plan - Empower Retirement

1 ][STD FBENED ][03/13/14 ][Page 1 of 2][B01:112913][RLFL/353990575 Beneficiary Designation401(k) PlanUse black or blue ink when completing this form. For questions regarding this form, contact Service Provider at State of Tennessee 401(k) PlanAParticipant InformationAccount extension identifies funds transferred to abeneficiary due to death, alternate payee due to divorceSocial Security NumberAccount Extensionor a participant with multiple /Last Name First Name of Birth( )Street AddressPersonal Phone Number( )

2 City State Zip CodeWork Phone NumberEmail AddressqMarried qUnmarriedDepartment/Payroll CenterBPrimary Beneficiary Designation (Attach an additional sheet to name additional beneficiaries.)%%of Account BalancePrimary Beneficiary NameRelationship%%of Account BalancePrimary Beneficiary NameRelationship%%of Account BalancePrimary Beneficiary NameRelationshipContingent Beneficiary Designation %%of Account BalanceContingent Beneficiary NameRelationship%%of Account BalanceContingent Beneficiary NameRelationship%%of Account BalanceContingent Beneficiary NameRelationshipCParticipant ConsentI have completed, understand and agree to all pages of this Beneficiary Designation form.

3 Subject to and in accordance with the terms ofthe Plan, I am making the above Beneficiary designations for my vested account in the event of my death. If I have more than one primarybeneficiary, the account will be divided as specified. If a primary Beneficiary predeceases me, his or her benefit will be allocated to thesurviving primary beneficiaries. Contingent beneficiaries will receive a benefit only if there is no surviving primary Beneficiary , as specified. Ifa contingent Beneficiary predeceases me, his or her benefit will be allocated to the surviving contingent beneficiaries.

4 If I fail to designatebeneficiaries, amounts will be paid pursuant to the terms of the Plan or applicable law. This Designation is effective upon execution anddelivery to Service Provider. If any information is missing, additional information may be required prior to recording my Designation supersedes all prior designations . Beneficiaries will share equally if percentages are not provided and any amounts unpaidupon death will be divided and contingent beneficiaries must separately total 100% in whole understand that Service Provider is required to comply with the regulations and requirements of the Office of Foreign Assets Control,Department of the Treasury ("OFAC").

5 As a result, Service Provider cannot conduct business with persons in a blocked country or anyperson designated by OFAC as a specially designated national or blocked person. For more information, please access the OFAC Web siteat: person who presents false or fraudulent information is subject to criminal and civil SignatureDate (Required)98986-02 Last NameFirst Security NumberNumber][STD FBENED ][03/13/14 ][Page 2 of 2][B01:112913][RLFL/353990575 DMailing InstructionsParticipantforward to Service ProviderGreat-West Retirement Services Regular Mail:PO Box 173764 Denver, CO 80217-3764 Phone: 1-800-922-7772 Fax: 1-866-745-5766 Website: Mail:8515 E.

6 Orchard RoadGreenwood Village, CO 80111