Fillable Tsp 3 Form Details

In the business world, there are many forms and templates that must be completed in order to keep operations moving smoothly. For example, one important form is the Tsp 3 fillable form. This form is used for tracking employee time and attendance, and it's important to ensure that all of the necessary information is filled out accurately. In this blog post, we'll take a look at what information needs to be included on the Tsp 3 fillable form, as well as some tips for completing it correctly.

Here is the details relating to the form you were looking for to fill out. It will tell you how long it takes to complete tsp 3 fillable form, exactly what parts you need to fill in and some further specific facts.

QuestionAnswer
Form NameTsp 3 Fillable Form
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other namestsp beneficiary form, tsp form 3, form tsp 3, tsp 3 form fillable

Form Preview Example

Thrift Savings Plan

Form TSP-3

Designation of Beneficiary

May 2017

For federal civilian employees, members of the uniformed services, and beneficiary participants

If you would like your TSP account to be distributed according to the statutory order of precedence, do not complete this form. (See the first page of the instructions for an explanation of the order of precedence.)

Use this form to designate a beneficiary or beneficiaries to receive your Thrift Savings Plan (TSP) account after your death. This Designation of Beneficiary form will stay in effect until you submit another valid Form TSP-3 naming other beneficiaries or canceling all prior designations. The beneficiary designation(s) you provide on this form will automatically cancel all previous designations you submitted. Complete this form in accordance with the instructions. Do not cross out, erase, or otherwise change any information you provide on this form. Make a copy of this form for your records and send the original to the TSP. If you are an active employee or service member, do not give this form to your agency or service.

Mail the original to: Thrift Savings Plan

P.O. Box 385021

Birmingham, AL 35238

Or fax to: 1-866-817-5023

If you have questions, call the toll-free ThriftLine at 1-877-968-3778 or the TDD at 1-877-847-4385. Outside the U.S. and Canada, please call 404-233-4400 (not toll free).

You will receive a confirmation of your designation once your form is processed.

Check to make sure of the following:

You provide your name and account number on each page that you submit to the TSP.

You print legibly.

You sign all pages you complete (including any extra pages you add) on the same date.

You have the same witness sign and date all pages—including any extra pages—after you sign and date the form. The witness cannot be named as a beneficiary.

You do not alter this form or any information you provide on it.

Your primary beneficiaries’ shares add up to 100%.

If you name contingent beneficiaries, you name a primary beneficiary for each contingent beneficiary.

The shares of contingent beneficiaries (if any) total 100% for each primary beneficiary.

You do not submit your will or direct us to make a designation according to your will.

You address this form to:

Thrift Savings Plan

P.O. Box 385021

Birmingham, AL 35238

Form TSP-3 (5/2017)

PREVIOUS EDITIONS OBSOLETE

THRIFT SAVINGS PLAN

TSP-3

DESIGNATION OF BENEFICIARY

I. PARTICIPANT INFORMATION—This applies to my:

Civilian

Uniformed Services

Beneficiary Participant Account

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

First Name

 

 

 

 

 

 

 

 

 

 

Middle Name

/

/

TSP Account NumberDate of Birth (mm/dd/yyyy)Daytime Phone (Area Code and Number)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Foreign address?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check here.

 

Street Address or Box Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address Line 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

State

 

 

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

II.CANCELLATION—To cancel all previous designations without designating new beneficiaries, check the box below. In the event of your death, payment from the TSP will be made according to the statutory order of precedence set by the United States Code (5 U.S.C. § 8424(d)).

Check here only to cancel all prior beneficiary designations without naming new beneficiaries. (Also complete Section IV.)

III. PRIMARY BENEFICIARY DESIGNATIONS

Relationship to you:

 

Spouse

Other Individual

 

Trust

 

Estate

 

Legal Entity/Corporation

 

Share:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Individual (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

 

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Trustee/Executor (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm/dd/yyyy)

%

Address:

Foreign address? Check here.

Relationship to you:

Spouse

Other Individual

Trust

Estate

Legal Entity/Corporation

 

 

Share:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID

Name of Individual (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

/

/

Name of Trustee/Executor (if applicable)

Date of Birth (mm/dd/yyyy)

Address:

Foreign address? Check here.

Relationship to you:

Spouse

Other Individual

Trust

Estate

Legal Entity/Corporation

 

 

Share:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID

Name of Individual (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

/

/

Name of Trustee/Executor (if applicable)

Date of Birth (mm/dd/yyyy)

Address:

Foreign address? Check here.

IV. SIGNATURES—This entire form is valid only if all pages are signed, dated, and then witnessed by the same person. The witness must be age 21 or older and cannot be a primary or contingent beneficiary of any portion of this TSP account. By signing below, the witness affirms that the participant either signed in the witness's presence or informed the witness that he or she signed it earlier.

 

 

 

 

/

 

 

/

 

 

 

 

Participant Signature

 

Date Signed (mm/dd/yyyy)

Check here and go to Page 2 if naming more than 3 primary beneficiaries.

/

/

Witness SignatureDate Signed (mm/dd/yyyy)Witness Print Full Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FORM TSP-3, Page 1 (5/2017)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PREVIOUS EDITIONS OBSOLETE

* P I I S 0 0 2 2 8 7 0 1 2 0 0 0 0 0 0 0 0 P I I S *

Do Not Write In This Section

FORM TSP-3, INFORMATION AND INSTRUCTIONS FOR PAGES 1 AND 2

This form stays in effect until you submit another valid Form TSP-3 naming other beneficiaries or canceling all prior designations. It does not affect the disposition of any other benefits you may have such as a FERS Basic Annuity, a CSRS annuity, or military retired pay.

SECTION I—Participant Information. For this and all sections of this form, carefully type or print the requested information inside the boxes, where provided, using black or dark blue ink. For beneficiary addresses print or type legibly in the spaces provided.

Complete this form only if you want payment to be made in a way other than the following statutory order of precedence:

1.

To your spouse

2.

If none, to your child or children equally, with the share due any

 

deceased child divided equally among that child’s descendants

3.

If none, to your parents equally or to your surviving parent

4.

If none, to the appointed executor or administrator of your estate

5.

If none, to your next of kin who is entitled to your estate under

 

the laws of the state in which you resided at the time of your

Correct

C O RR E C T

3 / 6 / 1 9 8 2

EXAMPLES

Incorrect

I NCORRECT

3 / 6 / 19 82

death

As used here, “child” means either a biological child or a child adopted by the participant. It does not include your stepchild or foster child unless you have adopted the child. Nor does it include your biological child if that child has been adopted by someone other than your spouse.

“Parents” does not include stepparents who have not adopted you.

Making a valid designation. To name specific beneficiaries to receive your TSP account after you die, you must complete this form, and

it must be received by the TSP on or before the date of your death. Only a Form TSP-3 is valid for designating beneficiaries to your TSP account(s); a will or court order (e.g., divorce decree) is not valid for the disposition of a TSP account. You may, however, designate your estate or a trust as a beneficiary on Form TSP-3.

You are responsible for ensuring that each page of your Form TSP-3 is properly completed, signed, and witnessed. Do not submit an altered form; it may be deemed invalid. If you need to correct or change the information you have entered on the form, start over on a new form.

Changing or canceling your designation of beneficiary. To cancel a Form TSP-3 already on file, follow the instructions for Section II.

Keep your designation (and your beneficiaries’ addresses) current. It is a good idea to review how you have designated your beneficiaries from time to time—particularly when your life situation changes (e.g., through marriage, divorce, the birth or adoption of a child, or the death of a beneficiary).

By law, the TSP must pay your properly designated beneficiary under all circumstances. For example, if you designate your spouse as a beneficiary of your TSP account, that spouse will be entitled to death benefits, even if you are separated or divorced from that spouse and have remarried. This is true even if the spouse you designated gave up all rights to your TSP account(s). Consequently, if your life situation changes, you may want to file a new Form TSP-3 that changes or cancels your current beneficiary designation.

Unless you designate a contingent beneficiary, the share of any primary beneficiary who dies before you do will be distributed proportionally among the surviving designated TSP beneficiaries. If none of your designated beneficiaries are alive at the time of your death, the statutory order of precedence will be followed.

Check the box that indicates whether you intend your beneficiary(ies) to receive funds from your civilian, uniformed services, or beneficiary participant account (i.e., an account inherited by the spouse of a deceased TSP participant). If you have a civilian and a uniformed services account and want to designate the same beneficiaries and shares for both accounts, check both boxes. To designate different beneficiaries for each account, you must submit two forms. If you have a civilian and/or uniformed services account in addition to a beneficiary participant account, you will need to complete an additional Form TSP-3 to designate beneficiaries for your beneficiary participant account. If you have more than one beneficiary participant account, you will need to complete a separate TSP-3 form for each beneficiary participant account since every beneficiary participant account has its own account number. Note: To avoid the possibility of having your form rejected, be sure to provide the correct account number (civilian, uniformed services, or beneficiary participant) and check the correct box(es) that corresponds to the account for which you want to designate beneficiaries.

If you have a foreign address, check the box to indicate this.

SECTION II—Cancellation. To cancel a Form TSP-3 already on file without naming new beneficiaries, check the box in this section, sign and date the form, and have it witnessed. If you check this box, your account will be paid according to the order of precedence described earlier. Do not complete this section if you intend to name new beneficiaries in Section III. Your new designation(s) will automatically cancel any previous designation(s) on file with the TSP.

Form TSP-3 (5/2017)

PREVIOUS EDITIONS OBSOLETE

Name:

TSP Account Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Last, First, Middle)

ADDITIONAL PRIMARY BENEFICIARY DESIGNATIONS

Make a copy of this blank page to designate additional primary beneficiaries.

Relationship to you:

 

Spouse

Other Individual

 

Trust

 

Estate

 

Legal Entity/Corporation

 

Share:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Individual (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

 

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Trustee/Executor (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm/dd/yyyy)

%

Address:

Foreign address? Check here.

Relationship to you:

Spouse

Other Individual

Trust

Estate

Legal Entity/Corporation

 

 

Share:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID

Name of Individual (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

/

/

Name of Trustee/Executor (if applicable)

Date of Birth (mm/dd/yyyy)

Address:

Foreign address? Check here.

Relationship to you:

Spouse

Other Individual

Trust

Estate

Legal Entity/Corporation

 

 

Share:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID

Name of Individual (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

/

/

Name of Trustee/Executor (if applicable)

Date of Birth (mm/dd/yyyy)

Address:

Foreign address? Check here.

Relationship to you:

Spouse

Other Individual

Trust

Estate

Legal Entity/Corporation

 

 

Share:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID

Name of Individual (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

/

/

Name of Trustee/Executor (if applicable)

Date of Birth (mm/dd/yyyy)

Address:

Foreign address? Check here.

Relationship to you:

Spouse

Other Individual

Trust

Estate

Legal Entity/Corporation

 

 

Share:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID

Name of Individual (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

/

/

Name of Trustee/Executor (if applicable)

Date of Birth (mm/dd/yyyy)

Address:

Foreign address? Check here.

 

 

 

 

/

 

 

/

 

 

 

 

Participant Signature

Date Signed (mm/dd/yyyy)

 

 

 

/

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check here if naming more primary beneficiaries. (See instructions for submitting additional pages.)

Witness Signature

Date Signed (mm/dd/yyyy)

 

 

Do Not Write In This Section

FORM TSP-3, Page 2 (5/2017)

PREVIOUS EDITIONS OBSOLETE

FORM TSP-3, INFORMATION AND INSTRUCTIONS FOR PAGES 1 AND 2 (continued)

SECTION III—Primary Beneficiary Designations. You may name any person, a trust, your estate, or a legal entity/corporation as a beneficiary. Note: If the beneficiary is a minor child, benefits will be made payable directly to the child. To designate a custodian for your minor child, you may want to consider using a Uniformed Transfer to Minors Act (UTMA) form. Contact the ThriftLine for additional information about this form.

Enter the share for each beneficiary as a whole percentage. Percentages for the primary beneficiaries must total 100%. Do not use fractions or decimals.

To name a primary beneficiary:

Check the box that indicates the beneficiary’s relationship to you.

For each individual you designate, enter the full name, share, address, and date of birth or Social Security number (SSN) or other tax ID (such as an Employer Identification Number [EIN]).

If the beneficiary is a trust, check the box marked “Trust.” Enter the name of the trust and the trustee’s name and address in the spaces indicated. Enter the EIN, if available. Leave the date of birth boxes blank. Note: Filling out this form will not create a trust; you must have a trust that is already established.

If the beneficiary is your estate, check the box marked “Estate.” Enter the name of the estate and the executor’s name and address in the spaces indicated. Enter the EIN, if available. Leave the date of birth boxes blank.

If the beneficiary is a legal entity or corporation, check the box marked “Legal Entity/Corporation.” Enter the name of the entity in the boxes indicated. Enter the legal representative’s name in the boxes marked “Trustee/Executor,” and provide the legal representative’s address. Enter the EIN, if known. Leave the date of birth boxes blank.

If you are naming more than 3 primary beneficiaries, use Page 2 of this form. Use photocopies of a blank Page 2 if you are naming more than that page allows. Enter your name and TSP account number on the top of each page, and follow the instructions for completing Section III. You must sign and date all additional pages. The same witness who signed Page 1 must also sign and date all pages that you submit to the TSP.

If you want to designate contingent beneficiaries, complete Section V on Page 3.

EXAMPLES. Below are examples of how to designate primary beneficiaries.

EXAMPLES OF DESIGNATING PRIMARY BENEFICIARIES

DESIGNATING MULTIPLE PRIMARY BENEFICIARIES

Relationship to you:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Share:

 

3

3

%

 

Spouse

 

Other Individual

 

Trust

 

Estate

Legal Entity/Corporation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

G

R

E

E

N

W

O

O

D

 

A

S

H

L

E

Y

 

D

A

N

I

E

L

L

E

 

 

 

 

 

 

9

2

6

 

 

3

5

 

8

0

7

2

 

Name of Individual (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

 

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

2

 

2

2

1

9

8

4

 

Name of Trustee/Executor (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm/dd/yyyy)

 

 

 

 

Address: 1066 CHURCHILL LANE, TUCSON, AZ 85735-3003

 

 

 

 

 

 

 

 

 

 

 

 

Foreign address?

 

 

 

 

 

 

 

 

 

 

 

 

Check here.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship to you:

 

Spouse

 

Other Individual

 

Trust

 

Estate

Legal Entity/Corporation

Share:

 

3

3

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P

O

I

N

T

E

R

 

M

A

R

Y

 

J

A

N

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9

1

5

 

 

9

9

 

2

1

3

5

 

Name of Individual (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

 

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

0

/

 

1

1

/

1

9

6

0

 

Name of Trustee/Executor (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm/dd/yyyy)

 

 

 

 

Address: 21 NORTH LAKEWOOD DRIVE, NEW ORLEANS, LA 70124-1920

 

 

Foreign address?

 

 

Check here.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship to you:

 

Spouse

 

Other Individual

 

Trust

 

Estate

Legal Entity/Corporation

Share:

 

3

4

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

J

O

H

N

S

O

N

 

C

H

R

I

S

T

O

P

H

E

R

 

A

N

D

R

E

W

 

 

 

 

 

9

0

2

 

 

3

7

 

6

6

3

3

 

Name of Individual (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

 

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6

/

 

1

3

/

1

9

9

1

 

Name of Trustee/Executor (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm/dd/yyyy)

 

 

 

 

DESIGNATING A TRUST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship to you:

 

Spouse

 

Other Individual

 

Trust

Estate

 

Legal Entity/Corporation

 

Share:

1

0

0

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

J

O

H

N

 

P

 

M

 

A

N

O

 

T

R

U

S

T

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Individual (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

 

 

/

 

 

 

 

 

 

E

R

I

C

 

P

 

M

A

N

O

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Trustee/Executor (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm/dd/yyyy)

 

 

 

 

Address: 1111 DELAWARE LANE, NEW YORK, NY 14607-8295

 

 

 

 

 

 

 

 

 

 

 

 

 

Foreign address?

 

 

 

 

 

 

 

 

 

 

 

 

 

Check here.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESIGNATING AN ESTATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship to you:

 

Spouse

 

Other Individual

 

Trust

Estate

 

Legal Entity/Corporation

 

Share:

1

0

0

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

S

T

A

T

E

 

O

F

 

R

U

T

H

 

R

 

J

O

N

E

S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Individual (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

 

 

 

/

 

 

 

 

 

 

M

A

R

L

A

 

M

C

C

O

Y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Trustee/Executor (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm/dd/yyyy)

 

 

 

 

Address: 150 ROSSMOYNE DRIVE, ALAMEDA, CA 94510-7481

 

 

 

 

 

 

 

 

 

 

 

 

 

Foreign address?

 

 

 

 

 

 

 

 

 

 

 

 

 

Check here.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESIGNATING A LEGAL ENTITY/CORPORATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship to you:

 

Spouse

 

Other Individual

 

Trust

Estate

 

Legal Entity/Corporation

 

Share:

1

0

0

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

T

H

E

 

X

Y

Z

 

F

O

U

N

D

A

T

I

O

N

 

 

 

 

 

 

 

 

 

 

 

 

7

9

 

 

9

9

9

 

9

9

9

9

 

 

Name of Individual (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

L

E

A

N

O

R

 

J

A

R

V

I

S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

 

 

 

/

 

 

 

 

 

 

Name of Trustee/Executor (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm/dd/yyyy)

 

 

 

 

Address: 1506 ARBOR ROAD, MIRAMAR, FL 33028-1234

Foreign address?

Address: 64730 CONNECTICUT AVENUE, SUITE 240A, BETHESDA, MD 20815-0637

Check here.

Foreign address? Check here.

SECTION IV—Signatures. Sign and date the form on all pages on the same date. Do not ask an individual you name as a beneficiary of your TSP account to witness your Form TSP-3. A person named as a primary or contingent beneficiary of your TSP account who is also your witness cannot receive a share of the account. The witness must be age 21 or older.

PRIVACY ACT NOTICE. We are authorized to request the information you provide on this form under 5 U.S.C. chapter 84, Federal Employees Retirement System. We will use this information to identify your TSP account and to process your request. In addition, this information may be shared with other federal agencies for statistical, auditing,

or archiving purposes. We may share the information with law enforcement agencies investigating a violation of civil or criminal law, or agencies implementing a statute, rule,

or order. It may be shared with congressional offices, private sector audit firms, spouses, former spouses, and beneficiaries, and their attorneys. We may disclose relevant portions of the information to appropriate parties engaged in litigation and for other routine uses as specified in the Federal Register. You are not required by law to provide this information, but if you do not provide it, we will not be able to process your request.

Form TSP-3 (5/2017)

PREVIOUS EDITIONS OBSOLETE

Name (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation
SSN/EIN/Tax ID or Date of Birth
Address:
Contingent to which primary beneficiary?
Foreign address? Check here.
Name of Trustee/Executor (if applicable)
Date of Birth (mm/dd/yyyy)
/
SSN/EIN/Tax ID
Name of Individual (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation
/

 

 

Name:

TSP Account Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Last, First, Middle)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V. CONTINGENT BENEFICIARY DESIGNATIONS

ontingent beneficiary must be linked to a primary beneficiary. You

cannot link a contingent beneficiary to another contingent beneficiary. Make a copy of this blank page to designate additional contingent beneficiaries.

Relationship to you:

Spouse

Other Individual

TrustEEstate

Legal Entity/Corporation

Share:

%

Relationship to you:

Spouse

Other Individual

 

Trust

 

Estate

 

Legal Entity/Corporation

 

Share:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Individual (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

 

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Trustee/Executor (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm/dd/yyyy)

%

Address:

Contingent to which primary beneficiary?

Foreign address? Check here.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

SSN/EIN/Tax ID or Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship to you:

Spouse

Other Individual

 

Trust

 

Estate

 

Legal Entity/Corporation

 

Share:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Individual (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

 

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Trustee/Executor (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm/dd/yyyy)

%

Address:

Contingent to which primary beneficiary?

Foreign address? Check here.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

SSN/EIN/Tax ID or Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship to you:

Spouse

Other Individual

 

Trust

 

Estate

 

Legal Entity/Corporation

 

Share:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Individual (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

 

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Trustee/Executor (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm/dd/yyyy)

%

Address:

Contingent to which primary beneficiary?

Foreign address? Check here.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID or Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

 

/

 

 

 

 

 

 

 

 

Check here if naming more

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

contingent beneficiaries. (See

 

Participant Signature

 

Date Signed (mm/dd/yyyy)

 

 

 

 

 

 

 

instructions for submitting

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

 

/

 

 

 

 

 

 

 

 

additional pages.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Witness Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Signed (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do Not Write In This Section

 

 

 

 

 

 

 

 

 

 

FORM TSP-3, Page 3 (5/2017)

PREVIOUS EDITIONS OBSOLETE

FORM TSP-3, INFORMATION AND INSTRUCTIONS FOR PAGE 3

SECTION V—Contingent Beneficiary Designations.

ou are not naming contingent beneficiariesoee. You may tdesignate e one or more contingent beneficiaries for each primary beneficiary you name. The contingent beneficiary(ies) you name will receive the portion of the TSP account that you designated for a specific primary beneficiary who dies before you do.

Example: Joe Brown is one of your two primary beneficiaries, and his share is 30% of your account. If you designate Mary Brown and Sue Brown (Joe‘s daughters) as his contingent beneficiaries, and each is to get 50%, each would get 50% of Joe‘s portion. Since Joe’s share is 30% of your account, each will get 15% of your account. (You cannot designate contingent beneficiaries for contingent beneficiaries. In this case, you cannot designate contingent beneficiaries for Mary or Sue Brown.) For another example of this situation, see Example 2 below.

Check the box that indicates the contingent beneficiary’s relationship to you. If you are only naming one contingent beneficiary for a primary beneficiary, the share for that contingent beneficiary must be 100%. If you name more than one contingent beneficiary for a primary beneficiary, the combined share values for those contingent beneficiaries must equal 100%.

Provide the identifying information for contingent beneficiaries according to the instructions for designating primary beneficiaries

in Section III. For each contingent beneficiary you designate, enter the full name, share, address, and Social Security number (SSN) or other tax ID (such as Employer Identification Number [EIN]). If you do not have all the requested information, you must provide at least the contingent beneficiary’s name and share. You must also provide the primary beneficiary’s name and tax ID information (e.g., SSN or EIN, if available) or date of birth.

If you want to name the same contingent beneficiary for multiple primary beneficiaries, list your contingent beneficiary multiple times in order to link it to each primary beneficiary.

If you are naming more contingent beneficiaries than will fit on one page, photocopy a blank Page 3 of this form. Enter your name and TSP account number on the top of each page and follow the instructions for completing Section V. You must sign and date all additional pages. The same witness who signed Page 1 must also sign and date all pages that you submit to the TSP.

Note: If a named beneficiary dies, you may prefer to submit another Form TSP-3 to change your designation(s).

EXAMPLES. Below are examples of how to designate contingent beneficiaries.

EXAMPLES OF DESIGNATING CONTINGENT BENEFICIARIES

EXAMPLE 1

Relationship to you:

Spouse Other Individual

 

Trust

Estate

Legal Entity/Corporation

Share:

 

1

0

0

%

 

 

 

 

 

 

 

 

 

 

 

 

 

G

R

E

 

E

N

W

O

O

D

 

T

A

Y

L

O

R

 

G

R

A

C

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Name of Individual (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

/

 

1

8

/

2

 

0

0

 

3

 

Name of Trustee/Executor (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm/dd/yyyy)

 

 

 

 

 

Address: 1066 CHURCHILL LANE, TUCSON, AZ 85735-3003

 

 

 

 

 

 

 

 

 

 

 

 

Foreign address?

 

 

 

 

 

 

 

 

 

 

 

 

Check here.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contingent to which primary beneficiary?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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9

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Name (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID or Date of Birth

 

 

 

 

 

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T

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EXAMPLE 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse Other Individual

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Share:

 

 

 

 

 

 

Relationship to you:

 

Trust

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Legal Entity/Corporation

 

 

5

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H

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9

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2

 

Name of Individual (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

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2

6

/

1

 

9

5

 

5

 

Name of Trustee/Executor (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm/dd/yyyy)

 

 

 

 

 

Address: 1492 ARIGOLD AENUE, ROCKLAWN, CA 94510-9876

 

 

Foreign address?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check here.

Contingent to which primary beneficiary?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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9

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9

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Name (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID or Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse Other Individual

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship to you:

 

Trust

Estate

Legal Entity/Corporation

Share:

 

 

5

 

0

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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9

4

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Name of Individual (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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1

2

 

 

6

1

 

9

6

 

2

 

Name of Trustee/Executor (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm/dd/yyyy)

 

 

 

 

 

Address:

2007 IRIS COURT, ROCKLAWN, CA 94510-9877

 

 

 

 

 

 

 

 

 

 

 

 

Foreign address?

 

 

 

 

 

 

 

 

 

 

 

 

Check here.

Contingent to which primary beneficiary?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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9

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9

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Name (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID or Date of Birth

 

 

 

 

 

I,,

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Relationship to you:

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1

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Name of Individual (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

 

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Name of Trustee/Executor (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm/dd/yyyy)

 

 

 

 

Address: 92 OAK STREET, BOISE, ID 83709-21

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Foreign address?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check here.

Contingent to which primary beneficiary?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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9

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Name (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID or Date of Birth

 

 

 

 

I, SSW

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EXAMP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Individual

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Share:

 

 

 

 

 

Relationship to you:

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1

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9

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Name of Individual (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

 

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

1

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3

0

/

1

 

9

8

3

 

Name of Trustee/Executor (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm/dd/yyyy)

 

 

 

 

Address: ARKANSAS DRIVE, CHICAO, IL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Foreign address?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check here.

Contingent to which primary beneficiary?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Name (Last, First, Middle)/Trust/Estate/Legal Entity or Corporation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN/EIN/Tax ID or Date of Birth

 

 

 

 

I,

Form TSP-3 (5/2017)

PREVIOUS EDITIONS OBSOLETE