OFFICER SALARY CONTINUATION AGREEMENT
Exhibit
10.11
THIS
AGREEMENT,
made
and entered into this 30th day of March, 2007, by and between Bank of ▇▇▇▇▇,
a
bank organized and existing under the laws of the State of Georgia (hereinafter
referred to as the “Bank”), and ▇▇▇▇▇▇▇ ▇. Hertha, an Officer of the Bank
(hereinafter referred to as the “Officer”), a member of a select group of
management employees of the Bank.
WHEREAS,
the
Officer has been and continues to be a valued Officer of the Bank;
WHEREAS,
the
purpose of this Agreement is to further the growth and development of the
Bank
by providing the Officer with supplemental retirement income, and thereby
encourage the Officer’s productive efforts on behalf of the Bank and the Bank’s
shareholders, and to align the interests of the Officer and those
shareholders.
WHEREAS,
it is
the desire of the Bank and the Officer to enter into this Agreement under
which
the Bank will agree to make certain payments to the Officer at retirement
or the
Officer’s Beneficiary in the event of the Officer’s death pursuant to this
Agreement;
ACCORDINGLY,
it is
intended that the Agreement be “unfunded” for purposes of the Employee
Retirement Income Security Act of 1974, as amended (“ERISA”) and not be
construed to provide income to the participant or beneficiary under the Internal
Revenue Code of 1986, as amended (the “Code”), particularly Section 409A of the
Code and guidance or regulations issued thereunder, prior to actual receipt
of
benefits; and
THEREFORE,
it is
agreed as follows:
|
I.
|
EFFECTIVE
DATE
|
The
Effective Date of this Agreement shall be March 29, 2006.
| II. |
FRINGE
BENEFITS
|
The
salary continuation benefits provided by this Agreement are granted by the
Bank
as a fringe benefit to the Officer and are not part of any salary reduction
plan
or an arrangement deferring a bonus or a salary increase. The Officer has
no
option to take any current payment or bonus in lieu of these salary continuation
benefits except as set forth hereinafter.
| III. |
DEFINITIONS
|
|
A.
|
Retirement
Date:
|
If
the
Officer remains in the continuous employ of the Bank, the Officer shall retire
from active employment with the Bank on the later of the Officer’s sixty-fifth
(65th)
birthday or Separation from Service.
|
B.
|
Normal
Retirement Age:
|
“Normal
Retirement Age” shall mean the date on which the Officer attains age sixty-five
(65).
| C. |
Plan
Year:
|
Any
reference to “Plan Year” shall mean a calendar year from January 1st
to
December 31st.
In the
year of implementation, the term “Plan Year” shall mean the period from the
effective date to December 31st
of the
year of the effective date.
| D. |
Termination
of Employment:
|
“Termination
of Employment” shall mean voluntary resignation of employment by the Officer or
the Bank’s discharge of the Officer without cause, prior to the Normal
Retirement Age.
| E. |
Separation
from Service:
|
“Separation
from Service” shall mean that the Officer has experienced a Termination of
Employment from the Bank. Where the Officer continues to perform services
for
the Bank following a Termination of Employment, however, and the facts and
circumstances indicate that such services are intended by the Bank and the
Officer to be more than “insignificant” services, a Separation from Service will
not be deemed to have occurred and any amounts deferred under this Agreement
may
not be paid or made available to the Officer. The determination of whether
such
services are considered “insignificant” will be based upon all facts and
circumstances relating to the termination and upon any applicable rules and
regulations issued under Section 409A of the Code. Military leave, sick leave,
or other bona fide leaves of absence are not generally considered terminations
of employment.
-
2
-
|
F.
|
Discharge
for Cause:
|
The
term
“for cause” shall mean any of the following that result in an adverse effect on
the Bank: (i) the commission of a felony or gross misdemeanor involving fraud
or
dishonesty; (ii) the willful violation of any banking law, rule, or banking
regulation (other than a traffic violation or similar offense); (iii) an
intentional failure to perform stated duties; or (iv) a breach of fiduciary
duty
involving personal profit. If a dispute arises as to discharge “for cause,” such
dispute shall be resolved by arbitration as set forth in this Agreement.
In the
alternative, if the Officer is permitted to resign due to inappropriate conduct
as defined above, the Board of Directors may vote to deny all benefits. A
majority decision by the Board of Directors is required for forfeiture of
the
Officer’s benefits.
|
G.
|
Change
of Control:
|
“Change
of Control” shall mean a change in ownership or control of the Bank as defined
in Treasury Regulation Section 1.409A-3(g)(5) or any subsequently applicable
Treasury Regulation.
|
H.
|
Restriction
on Timing of Distribution:
|
Notwithstanding
any provision of this Agreement to the contrary, distributions to the Officer
may not commence earlier than six (6) months after the date of a Separation
from
Service, as that term is used under Section 409A if, pursuant to Internal
Revenue Code Section 409A, the Officer is considered a “specified employee”
under Internal Revenue Code Section 416(i), of the Bank if any stock of the
Bank
is publicly traded on an established securities market or otherwise. In the
event a distribution is delayed pursuant to this paragraph, the originally
scheduled payment shall be delayed for six (6) months, and shall commence
instead on the first day of the seventh month following Separation from Service.
If payments are scheduled to be made in installments, the first six (6) months
of installment payments shall be delayed, aggregated, and paid instead on
the
first day of the seventh month, after which all installment payments shall
be
made on their regular schedule. If payment is scheduled to be made in a lump
sum, the lump payment shall be delayed for six (6) months and instead be
made on
the first day of the seventh month.
|
I.
|
Beneficiary:
|
The
Officer shall have the right to name a Beneficiary of the death benefit as
described in Paragraph IV herein. The Officer shall have the right to name
such
Beneficiary at any time prior to the Officer’s death and submit it to the Plan
Administrator (or Plan Administrator’s representative) on the form provided.
Once received and acknowledged by the Plan Administrator, the form shall
be
effective. The Officer may change a Beneficiary designation at any time by
submitting a new form to the Plan Administrator. Any such change shall follow
the same rules as for the original Beneficiary designation and shall
automatically supersede the existing Beneficiary form on file with the Plan
Administrator.
-
3
-
If
the
Officer dies without a valid Beneficiary designation on file with the Plan
Administrator, death benefits shall be paid to the Officer’s
estate.
If
the
Plan Administrator determines in its discretion that a benefit is to be paid
to
a minor, to a person declared incompetent, or to a person incapable of handling
the disposition of that person’s property, the Plan Administrator may direct
distribution of such benefit to the guardian, legal representative or person
having the care or custody of such minor, incompetent person or incapable
person. The Plan Administrator may require proof of incompetence, minority
or
guardianship as it may deem appropriate prior to distribution of the benefit.
Any distribution of a benefit shall be a distribution for the account of
the
Officer and the Beneficiary, as the case may be, and shall be a complete
discharge of any liability under the Agreement for such distribution
amount.
| IV. |
RETIREMENT
BENEFIT
|
Upon
attainment of the Retirement Date, the Bank shall pay the Officer an annual
benefit equal to Fifty Thousand and 00.100th
Dollars
($50,000.00). Said benefit shall be paid in equal monthly installments
(1/12th
of the
annual benefit) until the death of the Officer. Said payment shall be made
the
first day of the month following the date of such Separation from Service.
| V. |
DEATH
BENEFIT
|
| A. |
Pre-Retirement
Death Benefit:
|
In
the
event the Officer should die while actively employed by the Bank at any time
after the date of this Agreement but prior to the Officer attaining the
Retirement Date, the Bank will pay the accrued balance on the date of death,
of
the Officer’s accrued liability retirement account in one (1) lump sum, the
first day of the second month following the Officer’s death, to the
Beneficiary.
| B. |
Post-Retirement
Death Benefit:
|
Upon
the
death of the Officer, if there is a balance in the accrued liability retirement
account, such balance shall be paid in one (1) lump sum to the Beneficiary.
Said
payment due hereunder shall be made the first day of the second month following
the Officer’s death.
| VI. |
ACCRUED
LIABILITY RETIREMENT
ACCOUNT
|
The
Bank
shall account for this benefit using the regulatory accounting principles
of the
Bank’s primary federal regulator. The Bank shall establish an accrued liability
retirement account for the Officer into which appropriate reserves shall
be
accrued.
-
4
-
| VII. |
VESTING
|
The
Officer shall be vested in the accrued liability retirement account in
accordance with the following schedule to a maximum of one hundred percent
(100%).
|
Age
of Officer
|
Vested
(to a maximum of 100%)
|
|
Age
59 and under
|
0%
|
|
60
|
50%
|
|
61
|
60%
|
|
62
|
70%
|
|
63
|
80%
|
|
64
|
90%
|
|
65
|
100%
|
| VIII. |
TERMINATION
OF EMPLOYMENT
|
In
the
event that the employment of the Officer shall terminate prior to Normal
Retirement Age, by the Officer’s voluntary action, or by the Officer’s discharge
by the Bank without cause, then this Agreement shall terminate upon the date
of
such termination of employment and the Bank shall pay to the Officer an amount
of money equal to balance of the Officer’s accrued liability retirement account
on the date of said termination, multiplied by the Officer’s cumulative vested
percentage. This compensation shall be paid in one (1) lump sum the first
day of
the second month following Separation from Service.
In
the
event the Officer’s death should occur after such termination but prior to the
payment provided for in this paragraph, the balance shall be paid, in one
(1)
lump sum to the Beneficiary. Said payment due hereunder shall be made the
first
day of the second month following the decease of the Officer.
In
the
event the Officer shall be discharged for cause at any time, this Agreement
shall terminate and all benefits provided herein shall be forfeited.
| IX. |
CHANGE
OF CONTROL
|
If
the
Officer subsequently suffers a Termination of Employment (voluntarily or
involuntarily), except for cause, anytime subsequent to a Change of Control,
then the Officer shall receive the benefits stated in Paragraph IV herein
upon
attaining Normal Retirement Age, as if the Officer had been continuously
employed by the Bank until the Officer’s Normal Retirement Age.
-
5
-
| X. |
RESTRICTIONS
ON FUNDING
|
The
Bank
shall have no obligation to set aside, earmark or entrust any fund or money
with
which to pay its obligations under this Agreement. The Officer, their
beneficiary(ies), or any successor in interest shall be and remain simply
a
general creditor of the Bank in the same manner as any other creditor having
a
general claim for matured and unpaid compensation.
The
Bank
reserves the absolute right, at its sole discretion, to either fund the
obligations undertaken by this Agreement or to refrain from funding the same
and
to determine the extent, nature and method of such funding. Should the Bank
elect to fund this Agreement, in whole or in part, through the purchase of
life
insurance, mutual funds, disability policies or annuities, the Bank reserves
the
absolute right, in its sole discretion, to terminate such funding at any
time,
in whole or in part. At no time shall any Officer be deemed to have any lien,
right, title or interest in any specific funding investment or assets of
the
Bank.
If
the
Bank elects to invest in a life insurance, disability or annuity policy on
the
life of the Officer, then the Officer shall assist the Bank by freely submitting
to a physical exam and supplying such additional information necessary to
obtain
such insurance or annuities.
| XI. |
MISCELLANEOUS
|
|
A.
|
Alienability
and Assignment Prohibition:
|
Neither
the Officer, nor the Officer’s surviving spouse, nor any other Beneficiary under
this Agreement shall have any power or right to transfer, assign, anticipate,
hypothecate, mortgage, commute, modify or otherwise encumber in advance any
of
the benefits payable hereunder nor shall any of said benefits be subject
to
seizure for the payment of any debts, judgments, alimony or separate maintenance
owed by the Officer or the Officer’s Beneficiary, nor be transferable by
operation of law in the event of bankruptcy, insolvency or otherwise. In
the
event the Officer or any Beneficiary attempts assignment, commutation,
hypothecation, transfer or disposal of the benefits hereunder, the Bank’s
liabilities shall forthwith cease and terminate.
|
B.
|
Binding
Obligation of the Bank and any Successor in
Interest:
|
The
Bank
shall not merge or consolidate into or with another bank or sell substantially
all of its assets to another bank, firm or person until such bank, firm or
person expressly agree, in writing, to assume and discharge the duties and
obligations of the Bank under this Agreement. This Agreement shall be binding
upon the parties hereto, their successors, beneficiaries, heirs and personal
representatives.
-
6
-
|
C.
|
Amendment
or Revocation:
|
Subject
to Paragraph XIII, it is agreed by and between the parties hereto that, during
the lifetime of the Officer, this Agreement may be amended or revoked at
any
time or times, in whole or in part, by the mutual written consent of the
Officer
and the Bank. Any such amendment shall not be effective to decrease or restrict
any Officer’s accrued benefit under this Agreement, determined as of the date of
amendment, unless agreed to in writing by the Officer, and provided further,
no
amendment shall be made, or if made, shall be effective, if such amendment
would
cause the Agreement to violate Internal Revenue Code Section 409A. In the
event
this Agreement is terminated, such termination shall not cause a distribution
of
benefits, except under limited circumstances as permitted under Section 409A
(i.e., 30 days before or 12 months after a Change of Control event, upon
termination of all arrangements of the same type, or upon corporate dissolution
or bankruptcy).
|
D.
|
Gender:
|
Whenever
in this Agreement words are used in the masculine or neutral gender, they
shall
be read and construed as in the masculine, feminine or neutral gender, whenever
they should so apply.
|
E.
|
Headings:
|
Headings
and subheadings in this Agreement are inserted for reference and convenience
only and shall not be deemed a part of this Agreement.
|
F.
|
Applicable
Law:
|
The
laws
of the State of Georgia shall govern the validity and interpretation of this
Agreement.
|
G.
|
Partial
Invalidity:
|
If
any
term, provision, covenant, or condition of this Agreement is determined by
an
arbitrator or a court, as the case may be, to be invalid, void, or
unenforceable, such determination shall not render any other term, provision,
covenant, or condition invalid, void, or unenforceable, and the Agreement
shall
remain in full force and effect notwithstanding such partial
invalidity.
|
H.
|
Not
a Contract of Employment:
|
This
Agreement shall not be deemed to constitute a contract of employment between
the
parties hereto, nor shall any provision hereof restrict the right of the
Bank to
discharge the Officer, or restrict the right of the Officer to terminate
employment.
-
7
-
|
I.
|
Tax
Withholding:
|
The
Bank
shall withhold any taxes that are required to be withheld, under Section
409A of
the Code and regulations thereunder, from the benefits provided under this
Agreement. The Officer acknowledges that the Bank’s sole liability regarding
taxes is to forward any amounts withheld to the appropriate taxing
authority(ies).
|
J.
|
Opportunity
to Consult with Independent Advisors:
|
The
Officer acknowledges that he has been afforded the opportunity to consult
with
independent advisors of his choosing including, without limitation, accountants
or tax advisors and counsel regarding both the benefits granted to him under
the
terms of this Agreement and the: (i) terms and conditions which may affect
the
Officer’s right to these benefits; and (ii) personal tax effects of such
benefits including, without limitation, the effects of any federal or state
taxes, Section 280G of the Code, Section 409A of the Code and guidance or
regulations thereunder, and any other taxes, costs, expenses or liabilities
whatsoever related to such benefits, which in any of the foregoing instances
the
Officer acknowledges and agrees shall be the sole responsibility of the Officer
notwithstanding any other term or provision of this Agreement. The Officer
further acknowledges and agrees that the Bank shall have no liability whatsoever
related to any such personal tax effects or other personal costs, expenses,
or
liabilities applicable to the Officer and further specifically waives any
right
for himself or herself, and his or her heirs, beneficiaries, legal
representative, agents, successor and assign to claim or assert liability
on the
part of the Bank related to the matters described above in this paragraph.
The
Officer further acknowledges that he has read, understands and consents to
all
of the terms and conditions of this Agreement, and that he enters into this
Agreement with a full understanding of its terms and conditions.
|
K.
|
Permissible
Acceleration Provision:
|
Under
Section 409A(a)(3), a payment of deferred compensation may not be accelerated
except as provided in regulations by the Internal Revenue Code. Certain
permissible payment accelerations include payments necessary to comply with
a
domestic relations order, payments necessary to comply with certain conflict
of
interest rules, payments intended to pay employment taxes, and certain de
minimis payments related to the participant’s termination of the Officer’s
interest in the plan.
-
8
-
| XII. |
ADMINISTRATIVE
AND CLAIMS PROVISION
|
|
A.
|
Plan
Administrator:
|
The
“Plan
Administrator” of this Agreement shall be Bank of ▇▇▇▇▇. As Plan Administrator,
the Bank shall be responsible for the management, control and administration
of
the Agreement. The Plan Administrator may delegate to others certain aspects
of
the management and operation responsibilities of the Agreement including
the
employment of advisors and the delegation of ministerial duties to qualified
individuals.
| B. |
Claims
Procedure:
|
a. Filing
a Claim for Benefits:
Any
insured, Beneficiary, or other individual, (“Claimant”) entitled to benefits
under this Agreement will file a claim request with the Plan Administrator.
The
Plan Administrator will, upon written request of a Claimant, make available
copies of all forms and instructions necessary to file a claim for benefits
or
advise the Claimant where such forms and instructions may be obtained. If
the
claim relates to disability benefits, then the Plan Administrator shall
designate a sub-committee to conduct the initial review of the claim (and
applicable references below to the Plan Administrator shall mean such
sub-committee).
b. Denial
of Claim:
|
A
claim for benefits under this Agreement will be denied if the Bank
determines that the Claimant is not entitled to receive benefits
under the
Agreement. Notice of a denial shall be furnished the Claimant within
a
reasonable period of time after receipt of the claim for benefits
by the
Plan Administrator. This time period shall not exceed more than
ninety
(90) days after the receipt of the properly submitted claim. In
the event
that the claim for benefits pertains to disability, the Plan Administrator
shall provide written notice within forty-five (45) days. However,
if the
Plan Administrator determines, in its discretion, that an
extension of time for processing the claim is required, such extension
shall not exceed an additional ninety (90) days. In the case of
a claim
for disability benefits, the forty-five (45) day review period
may be
extended for up to thirty (30) days if necessary due to circumstances
beyond the Plan Administrator’s control, and for an additional thirty (30)
days, if necessary. Any
extension notice shall indicate the special circumstances requiring
an
extension of time and the date by which the Plan Administrator
expects to
render the determination on
review.
|
-
9
-
c. Content
of Notice:
|
The
Plan Administrator shall provide written notice to every Claimant
who is
denied a claim for benefits which notice shall set forth the
following:
|
| (i.) |
The
specific reason or reasons for the
denial;
|
|
(ii.)
|
Specific
reference to pertinent Agreement provisions on which the denial
is
based;
|
|
(iii.)
|
A
description of any additional material or information necessary
for the
Claimant to perfect the claim, and any explanation of why such
material or
information is necessary; and
|
|
(iv.)
|
Any
other information required by applicable regulations, including
with
respect to disability benefits.
|
d. Review
Procedure:
|
The
purpose of the Review Procedure is to provide a method by which
a Claimant
may have a reasonable opportunity to appeal a denial of a claim
to the
Plan Administrator for a full and fair review. The Claimant, or
his duly
authorized representative, may:
|
|
(i.)
|
Request
a review upon written application to the Plan Administrator. Application
for review must be made within sixty (60) days of receipt of written
notice of denial of claim. If the denial of claim pertains to disability,
application for review must be made within one hundred eighty (180)
days
of receipt of written notice of the denial of
claim;
|
|
(ii.)
|
Review
and copy (free of charge) pertinent Agreement documents, records
and other
information relevant to the Claimant’s claim for
benefits;
|
|
(iii.)
|
Submit
issues and concerns in writing, as well as documents, records,
and other
information relating to the
claim.
|
-
10
-
e. Decision
on Review:
A
decision on review of a denied claim shall be made in the following
manner:
|
(i.)
|
The
Plan Administrator may, in its sole discretion, hold a hearing
on the
denied claim. If the Claimant’s initial claim is for disability benefits,
any review of a denied claim shall be made by members of the Plan
Administrator other than the original decision maker(s) and such
person(s)
shall not be a subordinate of the original decision maker(s). The
decision
on review shall be made promptly, but generally not later than
sixty (60)
days after receipt of the application for review. In the event
that the
denied claim pertains to disability, such decision shall not be
made later
than forty-five (45) days after receipt of the application for
review. If
the Plan Administrator determines that an extension of time for
processing
is required, written notice of the extension shall be furnished
to the
Claimant prior to the termination of the initial sixty (60) day
period. In
no event shall the extension exceed a period of sixty (60) days
from the
end of the initial period. In the event the denied claim pertains
to
disability, written notice of such extension shall be furnished
to the
Claimant prior to the termination of the initial forty-five (45)
day
period. In no event shall the extension exceed a period of thirty
(30)
days from the end of the initial period. The extension notice shall
indicate the special circumstances requiring an extension of time
and the
date by which the Plan Administrator expects to render the determination
on review.
|
|
(ii.)
|
The
decision on review shall be in writing and shall include specific
reasons
for the decision written in an understandable manner with specific
references to the pertinent Agreement provisions upon which the
decision
is based.
|
|
(iii.)
|
The
review will take into account all comments, documents, records
and other
information submitted by the Claimant relating to the claim without
regard
to whether such information was submitted or considered in the
initial
benefit determination. Additional considerations shall be required
in the
case of a claim for disability benefits. For example, the
claim will be reviewed without deference to the initial adverse
benefits
determination and, if the initial
|
-
11
-
adverse
benefit determination was based in whole or in part on a medical judgment,
the
Plan Administrator will consult with a health care professional with appropriate
training and experience in the field of medicine involving the medical judgment.
The health care professional who is consulted on appeal will not be the same
individual who was consulted during the initial determination or the subordinate
of such individual. If the Plan Administrator obtained the advice of medical
or
vocational experts in making the initial adverse benefits determination
(regardless of whether the advice was relied upon), the Plan Administrator
will
identify such experts.
|
(iv.)
|
The
decision on review will include a statement that the Claimant is
entitled
to receive, upon request and free of charge, reasonable access
to, and
copies of, all documents, records or other information relevant
to the
Claimant’s claim for benefits.
|
|
f.
|
Exhaustion
of Remedies:
|
|
A
Claimant must follow the claims review procedures under this Agreement
and
exhaust his or her administrative remedies before taking any further
action with respect to a claim for
benefits.
|
|
C.
|
Arbitration:
|
If
claimants continue to dispute the benefit denial based upon completed
performance of this Agreement or the meaning and effect of the terms and
conditions thereof, then claimants may submit the dispute to an Arbitrator
for
final arbitration. The Arbitrator shall be selected by mutual agreement of
the
Bank and the claimants. The Arbitrator shall operate under any generally
recognized set of arbitration rules. The parties hereto agree that they and
their heirs, personal representatives, successors and assigns shall be bound
by
the decision of such Arbitrator with respect to any controversy properly
submitted to it for determination.
Where
a
dispute arises as to the Bank’s discharge of the Officer “for cause,” such
dispute shall likewise be submitted to arbitration as above described and
the
parties hereto agree to be bound by the decision thereunder.
|
XIII.
|
TERMINATION
OR MODIFICATION OF AGREEMENT BY REASON OF CHANGES IN THE LAW, RULES
OR
REGULATIONS
|
The
Bank
is entering into this Agreement upon the assumption that certain existing
tax
laws, rules and regulations will continue in effect in their current
-
12
-
form.
If
any said assumptions should change and said change has a detrimental effect
on
this Agreement, then the Bank reserves the right to terminate or modify this
Agreement accordingly. Any such termination or modification shall not be
effective to decrease or restrict any Officer’s Accrued Liability Retirement
Account under this Agreement, determined as of the date of amendment, unless
agreed to in writing by the Officer, and provided further, no amendment shall
be
made, or if made, shall be effective, if such termination or modification
would
cause the Agreement to violate Internal Revenue Code Section 409A. In the
event
this Agreement is terminated, such termination shall not cause a distribution
of
benefits, except under limited circumstances as permitted under Section 409A
(i.e., 30 days before or 12 months after a Change in Control event, upon
termination of all arrangements of the same type, or upon corporate dissolution
or bankruptcy). Upon a Change of Control, this paragraph shall become null
and
void effective immediately upon said Change of Control.
IN
WITNESS WHEREOF,
the
parties hereto acknowledge that each has carefully read this Agreement and
executed the original thereof on the first day set forth hereinabove, and
that,
upon execution, each has received a conforming copy.
|
BANK
OF ▇▇▇▇▇
|
|
|
Thomaston,
Georgia
|
|
| __________________________ |
By:_______________________________
|
|
Witness
|
(Bank
Officer other than Insured)
Title
|
| __________________________ | __________________________________ |
|
Witness
|
▇▇▇▇▇▇▇
▇. Hertha
|
-
13
-
BENEFICIARY
DESIGNATION FORM FOR THE OFFICER SALARY CONTINUATION AGREEMENT
|
I.
|
PRIMARY
DESIGNATIONS
|
||||||||||||||||||||
|
A.
|
Person(s)
as a Primary Designation:
(Please
indicate the percentage for each beneficiary.)
|
||||||||||||||||||||
|
1.
|
Name:
|
Relationship:
|
SS#:
|
%
|
|||||||||||||||||
|
Address:
|
|||||||||||||||||||||
|
(Street)
|
(City)
|
(State)
|
(Zip)
|
||||||||||||||||||
|
2.
|
Name:
|
Relationship:
|
SS#:
|
%
|
|||||||||||||||||
|
Address:
|
|||||||||||||||||||||
|
(Street)
|
(City)
|
(State)
|
(Zip)
|
||||||||||||||||||
|
3.
|
Name:
|
Relationship:
|
SS#:
|
%
|
|||||||||||||||||
|
Address:
|
|||||||||||||||||||||
|
(Street)
|
(City)
|
(State)
|
(Zip)
|
||||||||||||||||||
|
4.
|
Name:
|
Relationship:
|
SS#:
|
%
|
|||||||||||||||||
|
Address:
|
|||||||||||||||||||||
|
(Street)
|
(City)
|
(State)
|
(Zip)
|
||||||||||||||||||
|
II.
|
ESTATE
AND/OR TRUST AS PRIMARY DESIGNATIONS
|
||||||||||||||||||||
|
A.
|
Estate
as a Primary Designation:
An
Estate can still be listed even if there is no
will.
|
||||||||||||||||||||
|
My
Primary Beneficiary is The Estate of
|
as
set forth in the Last Will and
|
||||||||||||||||||||
|
(Insert
full name)
|
|||||||||||||||||||||
|
Testament
dated the
|
day
of
|
,
200
|
and
any codicils thereto.
|
||||||||||||||||||
|
B.
|
Trust
as a Primary Designation:
|
||||||||||||||||||||
|
Name
of the Trust:
|
|||||||||||||||||||||
|
Execution
Date of the Trust:
|
Name
of the Trustee:
|
||||||||||||||||||||
|
Beneficiary
of the Trust:
(please
indicate the percentage for each beneficiary):
|
|||||||||||||||||||||
|
Name(s):
|
|||||||||||||||||||||
|
Name(s):
|
|||||||||||||||||||||
|
Is
this an Irrevocable Life Insurance Trust?□
Yes □
No
|
|||||||||||||||||||||
|
(If
yes and this designation is for a Joint Beneficiary Designation
Agreement,
an Assignment of Rights form must
be completed.)
|
|||||||||||||||||||||
-
14 -
|
III.
|
SECONDARY
(CONTINGENT) DESIGNATIONS
|
|||||||||||||||||||
|
A.
|
Person(s)
as a Secondary (Contingent) Designation:
(Please
indicate the percentage for each beneficiary in the event of the
Primary’s
Death.)
|
|||||||||||||||||||
|
1.
|
Name:
|
Relationship:
|
SS#:
|
%
|
||||||||||||||||
|
Address:
|
||||||||||||||||||||
|
(Street)
|
(City)
|
(State)
|
(Zip)
|
|||||||||||||||||
|
2.
|
Name:
|
Relationship:
|
SS#:
|
%
|
||||||||||||||||
|
Address:
|
||||||||||||||||||||
|
(Street)
|
(City)
|
(State)
|
(Zip)
|
|||||||||||||||||
|
3.
|
Name:
|
Relationship:
|
SS#:
|
%
|
||||||||||||||||
|
Address:
|
||||||||||||||||||||
|
(Street)
|
(City)
|
(State)
|
(Zip)
|
|||||||||||||||||
|
4.
|
Name:
|
Relationship:
|
SS#:
|
%
|
||||||||||||||||
|
Address:
|
||||||||||||||||||||
|
(Street)
|
(City)
|
(State)
|
(Zip)
|
|||||||||||||||||
|
IV.
|
ESTATE
AND/OR TRUST AS SECONDARY (CONTINGENT)
DESIGNATIONS
|
|||||||||||||||||||
|
A.
|
Estate
as a Secondary (Contingent) Designation:
|
|||||||||||||||||||
|
My
Primary Beneficiary is The Estate of
|
as
set forth in the last will and
|
|||||||||||||||||||
|
Testament
dated the
|
day
of
|
,
200
|
and
any codicils thereto.
|
|||||||||||||||||
|
B.
|
Trust
as a Secondary (Contingent) Designation:
|
|||||||||||||||||||
|
Name
of the Trust:
|
||||||||||||||||||||
|
Execution
Date of the Trust:
|
Name
of the Trustee:
|
|||||||||||||||||||
|
Beneficiary
of the Trust:
(please
indicate the percentage for each beneficiary):
|
||||||||||||||||||||
|
Name(s):
|
||||||||||||||||||||
|
Name(s):
|
||||||||||||||||||||
|
Is
this an Irrevocable Life Insurance Trust?□
Yes □
No
|
||||||||||||||||||||
|
(If
yes and this designation is for a Joint Beneficiary Designation
Agreement,
an Assignment of Rights form must
be completed.)
|
||||||||||||||||||||
V. SIGN
AND DATE
This
Beneficiary Designation Form is valid until the participant notifies the
bank in
writing.
| __________________________ | ______________________________ |
|
▇▇▇▇▇▇▇
▇. Hertha
|
Date
|
-
15
-