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Celarity, Inc. 401(k) Profit Sharing Plan
Beneficiary Designation
#210487
Section 1 – Participant Information
Participant Name
Home Address
Marital Status
Date of Birth
Social Security #
 Married
 Not Married
This is a(n)
 Initial Designation  Change to a Prior Designation
Section 2 – Primary Beneficiary Designation
If the beneficiary designated herein is not solely the spouse of the employee and the employee is married, the spousal consent
section (Section 5) must be completed and signed by the spouse in the presence of a notary.
Name
Relationship
Date of Birth or
Social Security or
%
 Spouse,  Child,  Organization
Date of Trust
Trust ID Number
 Trust,  Other _______________
 If this beneficiary should remain a minor at the time of becoming a beneficiary, benefits will be paid under my State of
Residence’s Uniform Transfer to Minors Act or Uniform Gift to Minors Act, in which case
_______________________________________ shall act as guardian for this beneficiary.
(Insert Name)
Name
Relationship
Date of Birth or
Social Security or
%
 Spouse,  Child,  Organization
Date of Trust
Trust ID Number
 Trust,  Other _______________
 If this beneficiary should remain a minor at the time of becoming a beneficiary, benefits will be paid under my State of
Residence’s Uniform Transfer to Minors Act or Uniform Gift to Minors Act, in which case
_______________________________________shall act as guardian for this beneficiary.
(Insert Name)
Name
Relationship
Date of Birth or
Social Security or
%
 Spouse,  Child,  Organization
Date of Trust
Trust ID Number
 Trust,  Other _______________
 If this beneficiary should remain a minor at the time of becoming a beneficiary, benefits will be paid under my State of
Residence’s Uniform Transfer to Minors Act or Uniform Gift to Minors Act, in which case
_______________________________________shall act as guardian for this beneficiary.
(Insert Name)
Name
Relationship
Date of Birth or
Social Security or
%
 Spouse,  Child,  Organization
Date of Trust
Trust ID Number
 Trust,  Other _______________
 If this beneficiary should remain a minor at the time of becoming a beneficiary, benefits will be paid under my State of
Residence’s Uniform Transfer to Minors Act or Uniform Gift to Minors Act, in which case
_______________________________________shall act as guardian for this beneficiary.
(Insert Name)
The percentage allocated for primary beneficiary(ies) should total 100%.
NOTE: The beneficiary designated on this form revokes any and all previous designations of beneficiaries of the Plan. If one or more
beneficiaries within a class or category (that is, within the group of Primary Beneficiaries or within the group of Contingent
Beneficiaries) should predecease me, the remaining beneficiaries of that class or group shall share equally in the share of the
deceased beneficiary.
Beneficiary designation will not be valid if section 4 on reverse side is not signed.
Please complete and sign reverse side.
Celarity, Inc. 401(k) Profit Sharing Plan
Beneficiary Designation
#210487
Section 1 – Participant Information
Participant Name
Home Address
Marital Status
Date of Birth
Social Security #
 Married
 Not Married
This is a(n)
 Initial Designation  Change to a Prior Designation
Section 2 – Primary Beneficiary Designation
If the beneficiary designated herein is not solely the spouse of the employee and the employee is married, the spousal consent
section (Section 5) must be completed and signed by the spouse in the presence of a notary.
Name
Relationship
Date of Birth or
Social Security or
%
 Spouse,  Child,  Organization
Date of Trust
Trust ID Number
 Trust,  Other _______________
 If this beneficiary should remain a minor at the time of becoming a beneficiary, benefits will be paid under my State of
Residence’s Uniform Transfer to Minors Act or Uniform Gift to Minors Act, in which case
_______________________________________ shall act as guardian for this beneficiary.
(Insert Name)
Name
Relationship
Date of Birth or
Social Security or
%
 Spouse,  Child,  Organization
Date of Trust
Trust ID Number
 Trust,  Other _______________
 If this beneficiary should remain a minor at the time of becoming a beneficiary, benefits will be paid under my State of
Residence’s Uniform Transfer to Minors Act or Uniform Gift to Minors Act, in which case
_______________________________________shall act as guardian for this beneficiary.
(Insert Name)
Name
Relationship
Date of Birth or
Social Security or
%
 Spouse,  Child,  Organization
Date of Trust
Trust ID Number
 Trust,  Other _______________
 If this beneficiary should remain a minor at the time of becoming a beneficiary, benefits will be paid under my State of
Residence’s Uniform Transfer to Minors Act or Uniform Gift to Minors Act, in which case
_______________________________________shall act as guardian for this beneficiary.
(Insert Name)
Name
Relationship
Date of Birth or
Social Security or
%
 Spouse,  Child,  Organization
Date of Trust
Trust ID Number
 Trust,  Other _______________
 If this beneficiary should remain a minor at the time of becoming a beneficiary, benefits will be paid under my State of
Residence’s Uniform Transfer to Minors Act or Uniform Gift to Minors Act, in which case
_______________________________________shall act as guardian for this beneficiary.
(Insert Name)
The percentage allocated for primary beneficiary(ies) should total 100%.
NOTE: The beneficiary designated on this form revokes any and all previous designations of beneficiaries of the Plan. If one or more
beneficiaries within a class or category (that is, within the group of Primary Beneficiaries or within the group of Contingent
Beneficiaries) should predecease me, the remaining beneficiaries of that class or group shall share equally in the share of the
deceased beneficiary.
Beneficiary designation will not be valid if section 4 on reverse side is not signed.
Please complete and sign reverse side.
Celarity, Inc. 401(k) Profit Sharing Plan #210487
Section 3 – Contingent Beneficiary Designation
Name
Relationship
Date of Birth or
Social Security or
%
 Spouse,  Child,  Organization
Date of Trust
Trust ID Number
 Trust,  Other _______________
 If this beneficiary should remain a minor at the time of becoming a beneficiary, benefits will be paid under my State of
Residence’s Uniform Transfer to Minors Act or Uniform Gift to Minors Act, in which case
_______________________________________shall act as guardian for this beneficiary.
(Insert Name)
Name
Relationship
Date of Birth or
Social Security or
%
 Spouse,  Child,  Organization
Date of Trust
Trust ID Number
 Trust,  Other _______________
 If this beneficiary should remain a minor at the time of becoming a beneficiary, benefits will be paid under my State of
Residence’s Uniform Transfer to Minors Act or Uniform Gift to Minors Act, in which case
_______________________________________shall act as guardian for this beneficiary.
(Insert Name)
Name
Relationship
Date of Birth or
Social Security or
%
 Spouse,  Child,  Organization
Date of Trust
Trust ID Number
 Trust,  Other _______________
 If this beneficiary should remain a minor at the time of becoming a beneficiary, benefits will be paid under my State of
Residence’s Uniform Transfer to Minors Act or Uniform Gift to Minors Act, in which case
_______________________________________shall act as guardian for this beneficiary.
(Insert Name)
Name
Relationship
Date of Birth or
Social Security or
%
 Spouse,  Child,  Organization
Date of Trust
Trust ID Number
 Trust,  Other _______________
 If this beneficiary should remain a minor at the time of becoming a beneficiary, benefits will be paid under my State of
Residence’s Uniform Transfer to Minors Act or Uniform Gift to Minors Act, in which case
_______________________________________shall act as guardian for this beneficiary.
(Insert Name)
The percentage allocated for contingent beneficiary(ies) should total 100%.
Section 4 – Participant Statement
By reason of my signature I understand that my previous beneficiary designations are revoked, and that I may change my designations upon
request. Further, I understand and acknowledge that, in the event of my divorce (or marriage and subsequent divorce if I am currently
unmarried), it is my obligation to notify the Plan once my divorce is finalized. I understand and acknowledge that, only in the event that I do so
notify the Plan during my lifetime of my divorce will the divorce nullify any existing beneficiary designation on file with the Plan designating my
prior spouse as my beneficiary.
Participant Signature:___________________________________
Date:_______________________
Print Name:___________________________________________
Section 5 – Spousal Consent
(only complete this section if you are married and you are naming a non-spouse beneficiary as a
primary beneficiary)
I hereby consent to the designation of the above named beneficiary(s). In so consenting, I acknowledge that I waive all rights to the distribution of
any of the assets in the accounts of the Plan identified above, except to the specific extent which may be designated herein. I hereby acknowledge
that I understand: (1) that by consenting, I will forfeit part or all of the benefits that might otherwise be paid to me in the event of the death of my
spouse; (2) that my Spouse’s election to name a Primary Beneficiary other than or in addition to me is not valid unless I consent to it; and (3) that
my consent is irrevocable.
Date: ___________________________
Signature of Spouse______________________________
A notary must complete the following: Subscribed and sworn to before me this
day of
Month
Year
Signature of Notary_____________________________
Beneficiary Designation Definitions and Instructions
Instructions
Please complete all applicable sections of this form, execute the form under Section 4, and return the form to your Plan Administrator
representative.
 Section 1 – Participant Information
 Section 2 – Primary Beneficiary Designation
 Section 3 – Contingent Beneficiary Designation
 Section 4 – Participant Signature
 Section 5 – Spousal Consent (if applicable)
Ramifications of Not Submitting the Form
If you do not submit this completed form and do not have a beneficiary designation on file the Plan Document’s Standard Beneficiary
Designation shall apply. Please see your plan’s Summary Plan Description (SPD) for additional information regarding the application of
this provision.
How Marriage Affects Your Designation
 If you are married and your most recent Beneficiary Designation on file does not designate your spouse as the sole primary
beneficiary, and does not have spousal consent for this designation, your spouse will be beneficiary of 100% of your account
balance.
 If you are married and you do not designate that your spouse receive 100% of your vested account balance, then your spouse
must sign the spousal consent portion of this form in the presence of a notary public. As long as your spouse is your sole primary
beneficiary, his or her consent is not needed to name a contingent beneficiary.
 If you are single, you may use this form to designate any person as your beneficiary. If you marry before your account is
distributed, your spouse will become your sole primary beneficiary, as described above, unless you file a new Beneficiary
Designation Form and obtain the required spousal consent.
 If you are now married and should divorce your current spouse, you must change your beneficiary. If you fail to make another
designation, the 401(k) benefits will be distributed according to the Standard Beneficiary Designation. In the event that you
remarry, your new spouse will receive 100% of your death benefit, unless you designate another beneficiary with the written
consent of your new spouse, witnessed by a Notary Public.
Designating Minor Children
When designating minor children as beneficiaries, you may wish to utilize a state Uniform Transfer to Minors Act or Uniform Gift to
Minors Act designation. This type of designation allows you to name a guardian for the minor beneficiary without having to develop a
trust.
Other Important Items to Note
You are not limited to four primary and four contingent beneficiaries. To designate additional beneficiaries, please attach, date, and
sign a separate piece of paper with your additional designations.
When designating beneficiaries, please use whole percentages and be sure that the percentages for each group of beneficiaries
(primary and contingent) total 100%. Your primary beneficiary cannot be your contingent beneficiary. If you designate a trust as a
beneficiary, please include the trust’s name and address, the date the trust was created, and the trustee’s name.
If more than one person is named and no percentages are indicated, payment will be made in equal shares to primary beneficiary(ies)
who survive. If a percentage is indicated and a primary beneficiary(ies) do(es) not survive, the percentage of that beneficiary’s
designated share shall be divided equally among the surviving primary beneficiary(ies).
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