Sample Beneficiary Forms Prepared by the Author for Illustrative Purposes Only

• Author: Seymour Goldberg
• Profession: Senior partner in the law firm of Goldberg & Goldberg, P.C., Woodbury, New York
• Pages: 11-14

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 BIRTH SOCIAL SECURITY PERCENT

Jennifer L.

Goldberg

Wife 10/15/55 100-10-1000 100%

CONTINGENT BENEFICIARIES

NAME RELATIONSHIP DATE OF BIRTH SOCIAL SECURITY PERCENT

Cole Gold-

berg, per

stirpes

Son 03/15/75 200-20-2000 50%

Blake

Goldberg,

per stirpes

Son 01/31/77 201-30-3000 50%

Dated: January 15, 2016

Jason S. Goldberg