Sample Beneficiary Forms Prepared by the Author for Illustrative Purposes Only

AuthorSeymour Goldberg
ProfessionSenior partner in the law firm of Goldberg & Goldberg, P.C., Woodbury, New York
Pages11-14
11
SAMPLE BENEFICIARY
FORMS
PREPARED BY THE AUTHOR FOR
ILLUSTRATIVE PURPOSES ONLY
(These sample beneficiary forms may or may not be appropriate for
a particular individual and should only be used in consultation with a
professional advisor.)
SAMPLE IRA DESIGNATION OF BENEFICIARY FORM
(Primary wife, children contingent)
Jason S. Goldberg
80 Ira Road
Manhasset, New York 11030
Social Security No. 620- 40- 4000
Date of Birth: 03 / 15 / 50
IRA Account Number: 1234567
PRIMARY BENEFICIARIES
NAME RELATIONSHIP DATE OF BIRTHSOCIAL SECURITYPERCENT
Jennifer L.
Goldberg
Wife10/15/55100-10-1000 100%
CONTINGENT BENEFICIARIES
NAME RELATIONSHIP DATE OF BIRTHSOCIAL SECURITYPERCENT
Cole Gold-
berg, per
stirpes
Son03/15/75200-20-2000 50%
Blake
Goldberg,
per stirpes
Son01/31/77201-30-3000 50%
Dated: January 15, 2016
Jason S. Goldberg

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