Change of Beneficiary Form

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Change of Beneficiary Form PO Box 55932 • Boston, MA 02205-5932 • 800-525-3713

Use this form to add or change beneficiaries on your retirement account(s).  All beneficiaries will receive equal shares upon the death of account owner unless

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otherwise indicated. Beneficiary allocations must total 100%.

visit janus.com or fax form to 877-319-3852

 If more space is needed, please attach additional instructions.  Make sure you sign and date Section 4 (page 2).  Print in capital letters in black ink.  Questions? Call 800-525-3713. account?

1. What name is on your retirement account?

Owner’s First Name

Middle Initial

Last Name

Social Security Number

Date of Birth

Phone Number

Account Number(s)

2. Primary Beneficiaries: (If applicable, the share of a beneficiary who predeceases the account owner will be divided proportionally among the surviving beneficiaries. The sum of all primary beneficiary designations must equal 100%.)

_____________________________________________________________________

A. Spouse Non-Spouse Trust Other Entity Minor

B.

Name

_____________________________________________________________________ Social Security or Taxpayer ID Number

Date of Birth/UA Date of Trust

% of Account

_____________________________________________________________________ Custodian’s full name if beneficiary is a minor. Appoint one person as a custodian. You cannot name yourself as custodian.

_____________________________________________________________________ Non-Spouse Trust Other Entity Minor

Name

______________________________________________________________________ Social Security or Taxpayer ID Number

Date of Birth/UA Date of Trust

% of Account

_____________________________________________________________________ Custodian’s full name if beneficiary is a minor. Appoint one person as a custodian. You cannot name yourself as custodian.

_____________________________________________________________________

C. Non-Spouse Trust Other Entity Minor

Name

_____________________________________________________________________ Social Security or Taxpayer ID Number

Date of Birth/UA Date of Trust

% of Account

_____________________________________________________________________ Custodian’s Full name if beneficiary is a minor. Appoint one person as a custodian. You cannot name yourself as custodian.

Total (must equal 100%): ________

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3. Secondary Beneficiaries: (If left blank, any existing secondary beneficiaries will be removed from the account(s). Secondary beneficiaries only receive assets if the account owner has died and all primary beneficiaries predecease the owner or disclaim assets. The sum of all secondary beneficiary designations must equal 100%.)

_____________________________________________________________________

A. Spouse Non-Spouse Trust Other Entity Minor

B.

Name

_____________________________________________________________________ Social Security or Taxpayer ID Number

Date of Birth/UA Date of Trust

% of Account

_____________________________________________________________________________________________________________ Custodian’s full name if beneficiary is a minor. Appoint one person as a custodian. You cannot name yourself as custodian.

_____________________________________________________________________ Non-Spouse Trust Other Entity Minor

Name

_____________________________________________________________________ Social Security or Taxpayer ID Number

Date of Birth/UA Date of Trust

% of Account

____________________________________________________________________________________________________________ Custodian’s full name if beneficiary is a minor. Appoint one person as a custodian. You cannot name yourself as custodian.

_____________________________________________________________________

C. Non-Spouse Trust Other Entity Minor

Name

_____________________________________________________________________ Social Security or Taxpayer ID Number

Date of Birth/UA Date of Trust

% of Account

_____________________________________________________________________________________________________________ Custodian’s Full name if beneficiary is a minor. Appoint one person as a custodian. You cannot name yourself as custodian.

Total (must equal 100%): ________

4. Please read and sign below. 

Following the death of an account owner, Janus Services LLC does not have a duty to locate beneficiaries, determine marital status or take a position if the beneficiary designation is disputed. In such instances, Janus may delay the disbursement of assets until such a time that the parties resolve the dispute and sufficient documentation of beneficiary status has been provided. We recommend that you periodically review your beneficiary designations and promptly notify Janus of any necessary changes.



I certify that (if I am married and reside in a community property or marital property state) my spouse has knowledge of and consents to the designation of a non-spouse beneficiary for this account. (Please consult with a legal advisor regarding your beneficiary designation. Neither the custodian nor the plan sponsor will be liable for any consequences resulting from failure to accurately represent spousal consent.)



This will become part of the terms, conditions and representations of the shareholder’s application.

X Signature of Owner

296-11-00756 08-16

Date

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