Beneficiary Designation Form
Use this form to designate one or more beneficiaries on your United Bank Account listed below. PLEASE NOTE: This form cannot be used to designate beneficiaries on IRAs or Trust Accounts. To designate a beneficiary on your IRA or Trust Account, please visit a United Bank branch or call us at (866) 959-BANK(2265). For this request to be effective, all account owners are required to sign this form. Any POD beneficiary(ies) designated on this account prior to this date is hereby revoked.
The undersigned is (are) the owner(s) of:
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Name(s) of Account Holder(s)
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List all account numbers on which to add/change beneficiary (ies) – Savings, Money Market, and CDs only
I/We direct you to change the title of the above listed accounts to the following:
In Trust For:
1. _________________________________________________________________________________________________________________________________________
Name of New Beneficiary
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Social Security Number of Beneficiary Relation to Primary Account Holder
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Permanent Address
2.
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Name of New Beneficiary
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Social Security Number of Beneficiary Relation to Primary Account Holder
__________________________________________________________________________________________________________________________________________
Permanent Address
3.
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Name of New Beneficiary
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Social Security Number of Beneficiary Relation to Primary Account Holder
__________________________________________________________________________________________________________________________________________
Permanent Address
4.
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Name of New Beneficiary
__________________________________________________________________________________________________________________________________________
Social Security Number of Beneficiary Relation to Primary Account Holder
__________________________________________________________________________________________________________________________________________
Permanent Address
In addition to the Account Agreement and Disclosure, the following disclosures apply:
A POD beneficiary or beneficiaries may be named on an individual account or multiple-party account with a Right of Survivorship. The beneficiary or beneficiaries only receive the funds upon death of the owner of the account or, in the case of a multiple party account, the death of the last surviving owner. While the owner(s) are alive, the beneficiary(ies) have no access or right to the funds. The owner(s) may change the POD beneficiary at any time during their lifetime. Changes in the beneficiary designation(s) must be provided to United Bank in writing on a form and in a manner acceptable to United Bank and signed by all living account owner(s) and notarized.
Upon the death of the owner, or, for a multiple party account, upon the death of the last surviving owner, funds in the account(s) shall be made payable and distributed to the surviving beneficiary, or if more than one beneficiary, to the surviving beneficiaries equally. Between POD beneficiaries, there is no Right of Survivorship. If a beneficiary dies, the funds in the account are split equally among the beneficiaries that are alive when the owner or last surviving owner of a multiple party account dies. If no beneficiary survives the last owner, the estate of the last living account owner is entitled to the funds. A POD designation may not be altered by will and the funds pass by operation of law, not as part of the estate of the owner or last surviving owner of the account.
United Bank shall not be liable for any payment made in good faith reliance on this POD Beneficiary Designation.
Authentication of Signature
I/We acknowledge that my/our authorization above may have an effect on the amount of insurance offered by the Federal Deposit Insurance Corporation (FDIC) for which I/we may be eligible if the accounts were held under different account titles. For more information please visit www.FDIC.org. By signing this Agreement, I/we acknowledge that I/we have read and agree to the POD Designated Beneficiary Terms and Conditions stated herein. All account owners must sign for this form to be valid.
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Signature Primary Account Holder Date: mm/dd/yyyy
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Signature Co-Account Holder (A) Date: mm/dd/yyyy
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Signature Co-Account Holder (B) Date: mm/dd/yyyy
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Signature Co-Account Holder (C) Date: mm/dd/yyyy
The signatures above must be acknowledged before a United States Notary Public
STATE OF ___________________________________________________________
ss: ___________________________________________
COUNTY OF__________________________________________________________
On this _______ day of______________, 20_______before me, the undersigned notary public, personally appeared ________________________ proved to me through satisfactory evidence of identification, which were ______________________________ to be the person(s) whose name(s) is/are subscribed to this form and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument, the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument for the purposes contained above. WITNESS my hand and official seal.
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Notary Signature
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Notary Printed name Commission Expires Date: mm/dd/yyyy
Return Completed form to:
United Bank
Payment Operations Department
95 Elm St
West Springfield, MA 01089
INSTRUCTIONS:
1. All Accounts listed above MUST have the same title.
2. All Account Holders MUST sign. Beneficiary(ies) do(es) not sign.
3. This form MAY NOT be used to add/delete/change the name of any account holder.
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