Mony Form Change Beneficiary – Fill Out and Use

	 MONY Life Insurance	 MONY Life Insurance	Express Mail:	Change of Beneficiary and/or
	Company	Company of America	100 Madison St	Rightsholder (Owner)
	P.O. Box 4830	P.O. Box 4720	Syracuse, NY 13202
				(Page 1 of 6)
	Syracuse, New York 13221	Syracuse, New York 13221
				Form No. 10481 (10/2010)

INSTRUCTIONS FOR COMPLETING THIS FORM

Section 1. Designation of Beneficiary and Method of Payment

Payment will be made in one sum. Settlement Option is not available unless elected on Beneficiary, Rights and Settlement Option Request (Form 4113).

Complete the beneficiary designation (FIRST, SECOND), using the sample wordings on Page 2 as a guide for completing your designation. It is not necessary to designate a SECOND beneficiary, but the space is provided if you choose to do so. The relationship of the proposed beneficiary(ies), to the Insured person must be stated in Section 1.

Use the full legal name — Linda Smith, not Mrs. John Smith.

Current law requires us to request the name and address of each beneficiary (including the current list of living members in a group designation like “my children”) as well as the Relationship of each beneficiary named to the Insured. After completing the beneficiary designation in Section 1, you should provide this supplemental information below the name of each beneficiary noted on Page 4 in the space provided.

If you have named a person as beneficiary, the FINAL beneficiary will be the insured’s executors or administrators unless otherwise indicated. Is this your intent? Keep the rightsholder (owner) in mind. For example, if rights are vested in the Insured or the final rights revert to the Insured, the FINAL beneficiary is generally the executors or administrators of the Insured’s Estate. If, however, final rights are to be vested in someone other than the Insured (such as a spouse), the FINAL beneficiary is generally the executors or administrators of that person (surviving beneficiary).

Section 2. Designation of Rightsholder (Owner)

First Review Your Beneficiary Designation. Do you want to complete Section 1 in addition to Section 2?

To change the rightsholder (owner) on your policy, check the appropriate box. If rights are to be transferred to someone other than the Insured, complete 2. A and B. (See sample wordings on Page 2.)

Section 3. Signatures

To sign on behalf of a corporation:

1.An officer other than the Insured and other than the secretary must sign and the signing officer must specify his/her corporate title.

2.If the only two officers in the corporation are the Insured and the secretary, please submit a statement to that effect or indicate that fact in Section 3. See below for additional signature requirements:

Professional Corporation (“PC”)	Officer or Shareholder. Prefer someone who is both.
Registered Limited Liability
Partnership (“R.L.L.P.”)	Partner
Limited Liability Company (“L.L.C.”)	Member or Manager. Any other person would have to approve his/her
	authority under its opening agreement of Articles of Organization.
Professional Service L.L.C. (“P.S.L.L.C.”)	Same as L.L.C.

3.State the complete legal name of the Corporation as it appears in your Charter or Certificate of Incorporation. DO NOT use the corporate assumed name alone (its d/b/a).

4.The final beneficiary and/or rightsholder (owner) will be the Corporation’s successors or assigns.

To sign for a partnership:

1. A general partner other than the insured must sign in the following manner: (state full name of the partnership)

by:		. A limited partner may not sign for a partnership.
	(member of the firm)

2.The final beneficiary and/or rightsholder (owner) will be the Partnership’s successors or assigns. To sign on behalf of a tax-qualified plan:

1.The qualified trustee(s) must sign in the capacity of “trustee”, of the qualified/tax-sheltered plan, not individually.

2.State the full name of the tax-qualified plan as it appears in the plan.

GENERAL

A proposed Beneficiary Must Sign if designated to receive “as interest may appear” or in any way indicating the rightsholder’s (owner’s) indebtedness to the beneficiary, when that rightsholder is retaining any rights which would enable him at any time to eliminate the interest of the proposed beneficiary.

IMPORTANT: PLEASE READ THIS SPECIAL INSTRUCTION SHEET BEFORE COMPLETING THE FORM.

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SAMPLE WORDINGS

If you need help in wording a designation or if your designation is too long for this form, send us details of the change desired and we will prepare the form for you based on our interpretation of the information, it will then be subject to your approval.

SAMPLE WORDINGS FOR COMPLETING FIRST AND SECOND BENEFICIARY DESIGNATIONS IN SECTION 1.

If you wish to designate . . .	Please use this language . . .
SINGLE BENEFICIARY
a person	— Spouse, Jane Doe
Insured’s estate	— Insured’s executors or administrators
corporation	— XYZ Corporation, or its successors or assigns.
partnership	— Smith and Jones, a partnership, or its successors or assigns.
GROUP (more than one person) BENEFICIARY
children	— children, John Doe, Susan Doe and Frank Doe (will not include any other children)
	— children of Insured including John Doe, Susan Doe and Frank Doe
	— children of marriage of Insured and spouse, Mary Doe
	— children of marriage of Insured and spouse, Mary Doe, including John
	Doe and Susan Doe
parents	— Father, James Doe and mother, Frances Doe
named brothers and sister	— Sister, Jane Doe, and brothers John Doe, Frank Doe.
(nieces and nephews, aunts and uncles, etc.)
TRUST BENEFICIARY
Trustee under written trust (living trust)	— John Jones (XYZ Bank) as trustee or his (its) successor trustee under an Agreement
Provide the names of Trustee(s), the name of	dated May 1, 1978 made by and between the Insured and said trustee.
living trust, date of living trust, the name(s) of
grantor(s). If all identifying trust information is
not provided, a Statement as to Trustee/
Beneficiary Form 3559 will be required.

NOTE: If your Will specifies that some portion (or all) of your estate must be distributed (“poured over”) to a trust that is already in existance, (a living trust), then you can designate the trustee under the written trust agreement as the beneficiary, you need not designate the executor or a trustee under a testamentary trust.

SAMPLE WORDINGS FOR COMPLETING RIGHTSHOLDER (OWNER) DESIGNATIONS

IN SECTION 2.A and 2.B, IF APPLICABLE.

	If you wish to designate . . .	Please use this language . . .
	SINGLE RIGHTSHOLDER
	a person	— Jane Doe, spouse
	corporation
		— XYZ Corporation, or its successors or assigns.
	partnership
		— Smith and Jones, a partnership, or its successors or assigns.
	TRUST RIGHTSHOLDER
	Usually no other rightsholder, and no FINAL	— John Jones (or XYZ Bank) as trustee or his (its) successor trustee under an Agreement
	rightsholder, needs to be named after this (an	dated May 1, 1978 made by and between the Insured and said trustee.
	irrevocable trust) designation; but, if there is a
	need to do so, (a revocable trust) complete the
	FINAL rights (Section 2B) or send us full details
	and we will propose a designation for you.

GROUP (more than one person) RIGHTSHOLDER

Group rightsholders must act jointly and ownership interests cannot be apportioned.

children	— Insured’s children
	— children, Jane Doe, John Doe and Mary Doe
	— children of marriage of Insured and spouse, Mary Doe
	— children of marriage of Insured and spouse, Mary Doe, including John
	Doe and Susan Doe
parents	— Mother, Jane Doe and Father, James Doe -OR-
	Mother and Father of Insured, Jane and James Doe, respectively.

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Continued Next Page

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SAMPLE WORDINGS CONTINUED ..........

SINGLE PRIMARY RIGHTSHOLDER AND SINGLE CONTINGENT RIGHTSHOLDER

spouse, followed by child	— Spouse, Mary Doe, if living, if not, daughter, Jane Doe
SINGLE PRIMARY RIGHTSHOLDER AND GROUP CONTINGENT RIGHTSHOLDER
spouse, followed by unnamed children	— Spouse, Mary Doe, if living, if not, Insured’s children
spouse, followed by named children	— Spouse, Harry Doe, if living, if not, son, Frank Doe and daughter, Jane Doe
GROUP PRIMARY RIGHTSHOLDERS AND SINGLE CONTINGENT RIGHTSHOLDER
children, followed by spouse	— Insured’s children, if none is living, spouse, Mary Doe

General Information for Change in Ownership

•If the new Owner is a U.S. citizen, they must have a primary residence in the United States. If the person is a U.S.

Citizen but lives abroad, the change of ownership will require the approval of the AXA Equitable Anti-Money Laundering Office (AMLO).

•If the new Owner is not a U.S. citizen, they must have a primary resident address in the U.S. and have an unexpired visa or Green Card. Copies of the unexpired visa or Green Card must be submitted with this request. We will accept an unexpired visa in the following visa categories: A, E, G, H, I, K, L, N, NATO, P, R, S, T, TN, TD, U TPS or V. We will also need a copy of an unexpired visa and I-94 document.

•A Non-U.S. citizen that has a visitor’s visa, an expired Green Card or visa, no visa or has a visa in the following categories: B, C, D, F, J, M, Q, TWOV, will not be accepted as a new Owner and the ownership change must be declined under the AXA Financial Anti-Money Laundering policy.

•For Legal Resident Aliens: A copy of the unexpired Green Card or acceptable visa and I-94 form will be required to be submitted with the change of ownership request.

•For Trusts: Taxpayer Identification Number of the Trust and a copy of a Trust certification or significant pages and signature page of the Trust Agreement that proves the existence of the Trust, the name and date of the Trust Agreement,

as well as the name of the Trustee(s).

•For Partnerships: Pertinent page from the Partnership agreement that proves the Partnership exists and indicates the names of the Partners.

•For Private Corporations: Articles of Incorporation or copy of business license and documentation indicating the acting party has the authority to act on behalf of the Corporation.

•For Publicly Traded Corporations: No additional requirements need to be submitted.

•All non-resident individual and foreign business (Corporation, Trust, Partnership) new Owners require the approval of the AXA Equitable AMLO. In addition to the requirements outlined above, the AMLO also requires these new Owners to have a U.S. Bank account.

General Information for New Owner(s) concerning Taxpayer Identification Number

•Federal Law requires you to provide to us the correct Taxpayer Identification Number which matches your name.

•If you fail to provide the correct Taxpayer Identification Number, tax withholding may be required and penalties may apply.

•Your Taxpayer Identification Number is your Social Security Number if you are an individual and a U.S. person. A

U.S. person is a U.S. citizen, or a non-citizen of the United States who is a U.S. resident for tax purposes. If you are a foreign individual who is not eligible to apply for a Social Security Number, your Taxpayer Identification Number is your Individual Taxpayer Identification Number or “ITIN” issued by the IRS. If you are an entity (U.S. or foreign), your Taxpayer Identification Number is the Employer Identification Number or “EIN” issued by the IRS.

•In the case of a minor, the minor.s Social Security Number must be provided. If the minor does not have a Social

Security Number, the natural guardian for the minor owner may obtain one by applying to the Social Security Administration on Application Form SS-4. If the newly acquired number is not received by AXA Equitable/AXA Life and Annuity/MONY Life Insurance Company of America within 60 days, AXA Equitable/AXA Life and Annuity/MONY Life Insurance Company of America is required by law to withhold on any taxable interest being credited to the policy/ contract.

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General Information on USA PATRIOT Act – Customer Identification Program

•Section 326 of the USA PATRIOT Act outlines important information about procedures for opening new accounts

•To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.

•To comply with Section 326, AXA Equitable/AXA Life and Annuity/MONY Life Insurance Company of America will ask for your name, address, date of birth, and other information necessary to allow us to identify you when opening an account. We may also ask to see your driver.s license or other identifying documents.

You May Use This Form:

To change either the beneficiary or the rightsholder (or both).

For any number of policies, provided you are requesting an identical change for each policy.

To change the beneficiary for proceeds payable at the Insured’s death only for Family Plan policies issued prior to 1968. The beneficiary of the proceeds payable upon the death of the insured wife and insured children will remain as stated in the policy or previous family plan endorsement.

You may NOT use this form:

To change the beneficiary on any MONY Employee or FU Pension or Benefit Plans, Disability Insurance Policies. Send us details of changes required for such policies and we’ll prepare a request for the rightsholder’s signature.

For settlement options on non - qualified policies. Use BENEFICIARY, RIGHTS and SETTLEMENT OPTION REQUEST (Form 4113), which may be obtained from your MONY Field Underwriter. (Settlement Options are not available on qualified policies.)

-OR-

To release an assignment. Assignment of Policy/Release of Assignment (Form 3600) is required and may be obtained from your MONY Field Underwriter.

TAX CONSEQUENCES

An attorney should be consulted about possible tax consequences in the following instances:

(a)if the rightsholder is not the Insured and is not the beneficiary; (b) if the rightsholder designates joint rights to two or more individuals, as a gift; (c) if the rightsholder is a corporation and is not a beneficiary; (d) if rights are changed on an annuity issued after April 22, 1987; (e) a transfer to a person two or more generations younger than the transferor (generation skipping); (f) if the policy has a loan and the rights are being transferred as a gift.

INFORMATION ON DIVORCE

If you are required to designate an ex-spouse or children as beneficiary(ies) pursuant to a divorce decree or order, then the decree should be submitted to us. We will try to conform the beneficiary designation to the terms of the decree. An endorsement will be sent to you and will be deemed to be accepted by you unless you notify us of your rejection. If you currently have your ex-spouse listed as beneficiary, then you should either change the beneficiary to reflect your new choice of beneficiary or to reconfirm your desire to designate the ex-spouse despite the divorce. In most states, a divorce does not automatically extinquish the rights of an ex-spouse as beneficiary. Therefore an Insured who inadvertently leaves his/her ex-spouse as beneficiary after a divorce may cause payment of the death benefits to the ex-spouse even though such payment is contrary to his/her intent. If your ex-spouse

is the beneficiary and you do not want him/her to be a beneficiary, then you should submit a change of beneficiary request.

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MONY Life Insurance	MONY Life Insurance	Express Mail:	CHANGE FORM
Company	Company of America	100 Madison St	(RIGHTS, BENEFICIARY,
P.O. Box 4830	P.O. Box 4720	Syracuse, NY 13202	METHOD OF PAYMENT)
Syracuse, NY 13221	Syracuse, NY 13221		(Page 5 of 6)
	(Not licensed in WY and NY)
			Form No. 10481 (Rev. 10/2010)

If Insured’s name has changed, state new name and reason for change :

If more space is required, please print “See Attached”. The form and attachment(s) must include the policy number(s), have the same date, and be signed by the owner. Joint beneficiaries will receive equal shares proportionate to the number of those beneficiaries who survive the Insured. Proceeds will be payable in one sum.

1. PRIMARY

Are any named beneficiaries a Viatical or Life Settlement Company?

 Yes

 No

BENEFICIARY(IES)

if living, if not

(Relationship(s)

(Names of First Beneficiary(ies)

(Date(s) of Birth)

Please type or print full

name and indicate the

Phone number:

relationship to the

insured person

Beneficiary(ies) Address:

Beneficiary(ies) Social Security # :

CONTINGENT

BENEFICIARY(IES)

(Relationship(s)

(Names of First Beneficiary(ies)

(Date(s) of Birth)

if living, if not

Please type or print full

Phone number:

name and indicate

relationship to the

Beneficiary(ies) Address:

Beneficiary(ies) Social Security # :

insured person.

FINAL

If no beneficiary named above is living at the Insured’s death, the beneficiary is the Insured’s executors or administrators,

BENEFICIARY

unless checked:

 The executors or administrators of the survivor of all beneficiaries (the last designated beneficiary to die)

To be completed for

Is this ownership change in connection with a viatical or life settlement transaction?

Yes

No

change of Rights

Is the new owner a US citizen or a legal entity established under US law?

Yes

No

(owner)

If the new owner is a nominee, fiduciary or intermediary for a beneficial owner,

2. RIGHTS

is the beneficial owner a US citizen or a legal entity established under US law?

Yes

No

Rightsholder,

Please change the Policy(ies) so that all rights provided in “Rights (Ownership) Under Policy” (refer to #5 on Page 6)

Contract

belong exclusively to (if naming joint rightsholders, the following information needs to be provided for all named rightsholders):

holder (Owner) on

a.

 Insured/Annuitant

 Individual

Trust

 Partnership

 Corporation  Other

record remains

Full Name of Proposed Rightsholder(s)

unchanged Unless

Relationship to Insured/Annuitant

Date of Birth

this section is

Legal Residence (Full Street, City, State, Zip)

completed.

Mailing Address (if different from Legal Address)

Where two or more

Phone number

New Rightsholder Occupation and Type of Business

Rightsholders are

Soc Sec #/TIN (IRS Form W-9 signed by new rightsholder must be included)

Designated, those

All non-resident individual and foreign business new rightsholders must have a US Bank

Living shall act jointly

Account: Name of Bank

Account Number

Unless otherwise

b.

FINAL RIGHTSHOLDER (IF ALL PERSONS DESIGNATED IN a. PREDECEASE THE INSURED):

indicated.

 The Insured / Annuitant - Final Rightsholder will be the Insured if no box is checked.

 The executors and administrators of the rightsholder, if two or more rightsholders, the

executors or administrators of the survivor of said rightsholders (the last to die).

IRS Form W-9 must be

IF AN

 The contractholder’s spouse. Only check this box if contract is an Annuity (see note).

ANNUITY

NOTE ON ANNUITIES: If the contract has a Contingent Annuitant Provision, and if the primary Annuitant

Completed by the

is the Contractholder at the time of death, the Successor Contractholder must be designated as the

NEW RIGHTSHOLDER

Primary Contractholder’s Spouse for the Contingent Annuitant Provision to continue the contract. At the

and Submitted to the

death of the Primary Contractholder, the contract MUST be surrendered and the proceeds paid out if the

Company with new

Contractholder’s Spouse DOES NOT then become the Contractholder.

c.

If the policy(ies) provide for an endowment or life income at annuity commencement. The right to receive

Rightsholder’s TIN

such endowment or life income at annuity commencement belongs exclusively to the Insured/Annuitant.

3.SIGNATURES The undersigned Rightsholder (Owner) requests the Company to accept and record the designations above, to add the provisions on

page 6 of this form his/her/its policy/contract (if necessary to update it), to issue an endorsement consistent with the above designations or to accept

this form as an endorsement (whichever it deems appropriate), and to accept any material changes above that I have initialed or otherwise ratified. If

signing on behalf of a corporation or partnership, see “Instructions” Page 1, Section 3 - “Signatures”.

Signature

Witness

Date

of Owner FIRST NAME

INITIAL

LAST NAME

If Rightsholder (Owner) resides in Massachusetts, a Witness is mandatory

and a named beneficiary may not be a witness.

Additional

Signature FIRST NAME

INITIAL

LAST NAME

Rightsholder’s (Owner) Daytime Phone Number

FOR HOME OFFICE USE: Form Recorded and Endorsement Waived:

Date

By

MONY Life Insurance Company

For Agency Use Only:

 Pending Transaction: contact

 Policyowner

 FU

 Agency F.U. Full Address if not at Agency of Record

 Completed Transaction: contact

 Policyowner

 FU

 Agency

Print F.U. or ASA Name

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GENERAL PROVISIONS

(Page 6 of 6)

FOR HOME OFFICE USE ONLY

Endorsement No.

Endorsement to Agency

DO NOT DESTROY

PD 99

10481

Endorsement sent to

File with App #

10660

12388

PI 10

Policy/Statement Returned

Servicer’s Name

11330 LA

12491

11197 LA

BART

Agy

FU #

Date

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