Designation or Change of Beneficiary Request at a glance
What it is: Designation or Change of Beneficiary Request for State Farm Mutual Funds Individual Retirement Accounts, Tax Sheltered Accounts (TSA) under 403(b)(7), or Archer Medical Savings Accounts (MSA).
Who signs: Under Signature(s), sign on the Participant's Signature line and enter the Date.
A filled-in Designation or Change of Beneficiary Request example: a parent names her son as beneficiary
How to fill out Designation or Change of Beneficiary Request, box by box
Participant Information
Under Participant Information, enter First Name, MI, Last Name, Address, Social Security Number, City, State, ZIP Code, Account Number and Telephone Number.
Mark Single or Married under Marital Status.
Designation of Beneficiary: Primary
By completing this form you revoke any prior death beneficiary designation and name the following as the beneficiary(ies) of this account.
Under Designation of Beneficiary, for each PRIMARY BENEFICIARY(IES), enter Name, SSN/TIN, Relationship, Date of Birth (Month/Day/Year), % of Account, Street, City, State and ZIP Code; Total = 100%.
To name more than four primary or secondary beneficiaries, attach a separate page and include, for each beneficiary, all of the information requested on this form. Sign and date the additional page. Have your spouse/partner sign the page, if required.
SECONDARY BENEFICIARY(IES)
For each SECONDARY BENEFICIARY(IES), enter Name, SSN/TIN, Relationship, Date of Birth (Month/Day/Year), % of Account, Street, City, State and ZIP Code; Total = 100%.
Signature of Spouse/Partner
Signature of Spouse/Partner (if required): spouse or partner's signature is required if the spouse/partner is not the sole primary beneficiary for this account and the spouse/partner and/or Participant resides in Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington or Wisconsin.
By signing, the spouse/partner voluntarily and irrevocably consents to the beneficiary designation and waives all rights he/she may have with respect to the account, except for any rights provided under the applicable Custodial Account Agreement.
More rules for Designation or Change of Beneficiary Request
This form is deemed valid by the Custodian if the following requirements have been met: the beneficiary information is complete, it is signed and dated by the Participant, your spouse/partner has signed the form if required, and it is filed with the Custodian prior to your death.
See the applicable State Farm Mutual Funds Custodial Account Agreements for additional provisions.
If you wish to establish a transfer on death beneficiary on your non-tax qualified State Farm Mutual Fund account, please call and request a Designation or Change of Transfer on Death (TOD) Beneficiary Form.
If you have any questions or need additional information before completing this form, please call 1-800-447-4930.
Common questions about Designation or Change of Beneficiary Request
Where do I file it?
Please fax or mail all signed completed forms to: State Farm Mutual Funds P.O. Box 219548 Kansas City, Missouri 64121-9548 FAX: 1-816-471-4832
Sources
[1] State Farm Mutual Funds Designation or Change of Beneficiary Request (the served file; no issuer file found) (the Official source link on this page).
