Saturna Capital Form 401 K – Fill Out and Use This PDF

401(k) Beneficiary Designation Form

I. Notice of Surviving Spouse’s Benefit

Under this Plan, the surviving spouse of a deceased Participant is generally entitled to a “surviving spouse’s benefit” equal to the Participant’s vested account balance at the time of death.

Unless the surviving spouse’s benefit is waived, a Participant may not designate that any portion of his or her vested account balance be paid as a death benefit to a beneficiary or beneficiaries other than his or her surviving spouse. For example, if a Participant designates his or her parents as beneficiaries and later marries but dies without having changed his or her beneficiary designation, the entire vested account balance will be paid to the surviving spouse rather than the deceased Participant’s parents. Similarly, if a married Participant designates that his or her vested account be divided in equal shares among the surviving spouse and their three children but the surviving spouse’s benefit is not waived, the surviving spouse must receive the entire vested account balance.

The surviving spouse’s benefit cannot be waived unless the spouse gives his or her written consent (Part III of this form) or the Participant certifies that he or she does not know the whereabouts of the spouse. To become effective, this form must be properly completed and submitted to the Plan Administrator (Employer).

II. Designation of Beneficiary / Optional Waiver of Surviving Spouse’s Benefit

As a Participant in the above Plan, I hereby revoke any prior beneficiary designation and direct that any benefits payable upon my death be paid to the following beneficiary/beneficiaries. The total share for the Primary Beneficiaries must equal 100% and the total share for the Secondary Beneficiaries, if any, must equal 100%.

If none of the Primary Beneficiaries designated above survive me, payment shall be made to the following Secondary Beneficiaries:

401(k) Beneficiary Designation Form

II. Designation of Beneficiary / Optional Waiver of Surviving Spouse’s Benefit (continued)

Unless otherwise specified on page 1, if none of the beneficiaries designated above survive me, payment shall be made pursuant to the applicable provisions of the Plan.

You must check A, B, C or D below:

A. I am not married. I understand that if I do marry, my surviving spouse will be entitled to my entire vested account balance unless I file a new Beneficiary Designation Form with my spouse’s written consent.

B. I am married, but Part III of this form is not completed because I have designated my spouse as the Primary Beneficiary of my entire vested account balance.

C. Subject to my spouse’s written consent (Part III of this form), I have designated that all or part of my vested account balance be paid to one or more beneficiaries other than my spouse.

D. I am married, but I have designated that all or part of my vested account balance be paid to one or more beneficiaries other than my spouse. Part III of this form has not been completed because I do not know the whereabouts of my spouse. I agree to inform the Plan Administrator if I learn the whereabouts of my spouse.

Dated at		, this		day of		, 20		.
	City, State

Signature of Participant:

Name of Participant (print or type)

III.Spouse’s Consent (Must be completed if Participant checks C above)

I am the spouse of the Participant identified above. I hereby consent to my spouse’s designation of the beneficiary(ies) identified above. I further acknowledge my understanding that:

1.My spouse’s designation that all or part of his or her vested account balance be paid to one or more beneficiaries other than myself is not valid unless I consent to it;

2.I am waiving the right to be the sole Primary Beneficiary of my spouse’s death benefit under the Plan; and

3.My consent is irrevocable (check one of the following):

until my spouse changes his or her designation of beneficiary(ies). At that time I must consent to any change in beneficiaries, or

even if my spouse changes his or her designation of beneficiary(ies). My spouse may change his or her beneficiary(ies) without my consent.

Dated at		, this		day of		, 20		.
	City, State

Signature of Participant’s Spouse

						Name of Participant’s Spouse (print or type)
Witnessed by:						Authorized Representative of
						Plan Administrator:
Notary Public, State of						OR
My Commission (is permanent/expires)
						Name of Representative (print or type)
401(k) BDF-20111201							Page 2 of 2