Fillable Irgefm-004 Iraben IRA Beneficiary Change

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Irgefm-004 Iraben IRA Beneficiary Change

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1 of 2
IRA Beneciary Change
Traditional
(
including SEP/SARSEP
)
, Roth and SIMPLE IRAs
11/18
Continued on next page
Important: The beneciaries named on this form will replace any existing beneciary information listed on your account. You must
specify ALL Primary and Contingent Beneciaries on this form even if you are changing only one beneciary.
1
General information
Please type or print clearly.
First name of IRA owner MI Last
Address City State ZIP
( )
Email address
*
Daytime phone
□
Check here if the mailing address listed above is new. Our records will be updated accordingly.
The beneciary designation below only applies to the following account(s):
* Your privacy is important to us. For information on our privacy policies, visit www.americanfunds.com.
2
Beneciarydesignation
We encourage you to consult an advisor regarding the tax-law and estate planning implications of your beneciary designation. All stated percentages
must be whole percentages
(
e.g., 33%, not 33.3%
)
. If the percentages do not add up to 100%, each beneciary’s share will be based proportionately
on the stated percentages. When a percentage is not indicated, the beneciaries’ shares will be divided equally.
Notes: • Your spouse may need to sign in Section 3. If you wish to customize your designation or need more space, attach a separate page.
• If you name a trust as beneciary, provide the full legal name of the trust. Example: “The Davis Family Trust.”
A. Primary Beneciary
(
ies
)
: If any designated Primary Beneciary
(
ies
)
dies before I do, that beneciary’s share will be divided proportionately
among the surviving Primary Beneciaries.
1.
□ □ □ %
First and last name or trust name
(
print
)
Spouse Nonspouse Trust Date of birth or trust
(
mm/dd/yyyy
)
Address City State ZIP SSN/TIN
2. □ □ □ %
First and last name or trust name
(
print
)
Spouse Nonspouse Trust Date of birth or trust
(
mm/dd/yyyy
)
Address City State ZIP SSN/TIN
3. □ □ □ %
First and last name or trust name
(
print
)
Spouse Nonspouse Trust Date of birth or trust
(
mm/dd/yyyy
)
Address City State ZIP SSN/TIN
Clear and reset form
2 of 2
IRA Beneciary Change
Traditional
(
including SEP/SARSEP
)
, Roth and SIMPLE IRAs
2
Beneciarydesignation
(
continued
)
Important: 2-A must be completed prior to completing 2-B.
B. Contingent Beneciary
(
ies
)
: If no Primary Beneciary survives me, pay my benets to the following Contingent Beneciary
(
ies
)
. If any
designated Contingent Beneciary
(
ies
)
dies before I do, that beneciary’s share will be divided proportionately among the surviving
Contingent Beneciaries.
1.
□ □ □ %
First and last name or trust name
(
print
)
Spouse Nonspouse Trust Date of birth or trust
(
mm/dd/yyyy
)
Address City State ZIP SSN/TIN
2. □ □ □ %
First and last name or trust name
(
print
)
Spouse Nonspouse Trust Date of birth or trust
(
mm/dd/yyyy
)
Address City State ZIP SSN/TIN
3
Spousalconsenttobeneciarydesignation—ifrequired
If you are married to the IRA owner named in Section 1, and he or she designated a Primary Beneciary(ies) other than you, please consult your
nancial advisor about the state-law and tax-law implications of this beneciary designation, including the need for your consent.
I am the spouse of the individual named in Section 1, and I expressly consent to the beneciary(ies) designated in Section 2 or attached.
I acknowledge that neither the custodian nor any afliate of the custodian shall be liable for any claims, losses, damages, expenses or taxes
(including penalties and interest) arising out of or in any manner, directly or indirectly, connected with this IRA Beneciary Change form.
X
/ /
Name of spouse
(
print
)
Signature of spouse Date
(
mm/dd/yyyy
)
This document may not be signed using Adobe Acrobat Reader’s "ll and sign" feature.
4
SignatureofIRAowner—required
I have expressly selected the beneciary(ies) listed in Section 2 or attached. I acknowledge that neither the custodian nor any afliate of the
custodian shall be liable for any claims, losses, damages, expenses or taxes (including penalties and interest) arising out of or in any manner,
directly or indirectly, connected with this IRA Beneciary Change form.
X
/ /
Signature of IRA owner Date
(
mm/dd/yyyy
)
This document may not be signed using Adobe Acrobat Reader’s "ll and sign" feature.
Li t. No. IRG EFM- 004-1118O CGD/9083-S66220 © 2018 Capital Group. All rights reserved. Securities offered through American Funds Distributors, Inc.
Virginia Service Center
American Funds Service Company
P.O. Box 2560
Norfolk, VA 23501-2560
Overnight mail address
5300 Robin Hood Rd.
Norfolk, VA 23513-2430
Fax (888) 421-4371
Please mail or
fax this form to
the appropriate
service center.
(
If you live outside
the U.S., mail the
form to the Indiana
Service Center.
)
If you have questions or require more information, contact your nancial advisor or call American Funds Service Company at
(
800
)
421-4225.
Indiana Service Center
American Funds Service Company
P.O. Box 6164
Indianapolis, IN 46206-6164
Overnight mail address
12711 N. Meridian St.
Carmel, IN 46032-9181
Fax (888) 421-4371
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Irgefm-004 Iraben IRA Beneficiary Change

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Completed 21 July 2020

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