TRANSFER ON DEATH FORM
Sign and return original form to US Energy Development Corporation at 2350 N Forest Rd, Getzville NY 14068.
For assistance, please contact the Investor Relations desk at 800-636-7606 x349
A. INVESTOR INFORMATION
Investor(s) Name:
Social Security Number / TIN:
State:
City
Street Address:
Zip Code:
Program(s) Invested In (Include # of Units)
_________________
_________________
_________________
_________________
_________________
B. DESIGNATE YOUR BENEFICIARY
Primary Beneficiary:
Upon my death, the beneficiary shall be:
Owners/Trust Name:
Type:
Individual
% Ownership:
Partnership
Corporation
Other: _________________
State:
City
Street Address:
Social Security Number / TIN:
Relationship:
Zip Code:
Telephone Number:
C. DESIGNATE YOUR BENEFICIARY (If % Ownership listed in Section B does not total 100%)
Primary Beneficiary:
Upon my death, the beneficiary shall be:
Owners/Trust Name:
Type:
Individual
Street Address:
Social Security Number / TIN:
Rev. Date: 01/14
% Ownership:
Partnership
Corporation
Relationship:
Other: _________________
State:
City
Zip Code:
Telephone Number:
_________________
Initials
Continued on Page 2
D. DESIGNATE YOUR BENEFICIARY (If % Ownership listed in Sections B & C do not total 100%)
Primary Beneficiary:
Upon my death, the beneficiary shall be:
Owners/Trust Name:
Type:
Individual
% Ownership:
Partnership
Corporation
Relationship:
Other: _________________
State:
City
Street Address:
Social Security Number / TIN:
Zip Code:
Telephone Number:
If additional beneficiaries are desired, please check the box below and attach a separate sheet
listing names, relationships, and birth dates.
I have attached additional beneficiary instructions.
E. DESIGNATE YOUR CONTINGENT BENEFICIARY
Contingent Beneficiary
(If Primary Beneficiary is not living at the time of my death)
Owners/Trust Name:
Type:
Individual
% Ownership:
Partnership
Corporation
Relationship:
Other: _________________
State:
City
Street Address:
Social Security Number / TIN:
Zip Code:
Telephone Number:
Primary Beneficiary Affected:
F. DESIGNATE YOUR SECOND CONTINGENT BENEFICIARY
Contingent Beneficiary
(If Primary Beneficiary is not living at the time of my death)
Owners/Trust Name:
Type:
Individual
Street Address:
Social Security Number / TIN:
% Ownership:
Partnership
Corporation
Relationship:
Other: _________________
State:
City
Zip Code:
Telephone Number:
Primary Beneficiary Affected:
Rev. Date: 01/14
_________________
Initials
Continued on Page 3
G. DESIGNATE YOUR THIRD CONTINGENT BENEFICIARY
Contingent Beneficiary
(If Primary Beneficiary is not living at the time of my death)
Owners/Trust Name:
Type:
Individual
% Ownership:
Partnership
Corporation
Other: _________________
City
Street Address:
Social Security Number / TIN:
Relationship:
State:
Zip Code:
Telephone Number:
Primary Beneficiary Affected:
H. SPOUSAL CONSENT
Any resident of a community property state (currently Alaska, Arizona, California, Idaho, Louisiana, Nevada, New
Mexico, Texas, Washington and Wisconsin) who designates beneficiaries other than a spouse must obtain the
spouse’s consent.
I consent to (i) the naming of another person as a primary beneficiary of this account or (ii) the naming of myself as
primary beneficiary and others as contingent beneficiaries of this account. I give any interest in these assets to the
account owner, to the extent necessary to accomplish the beneficiary designation made above.
Signature of Owner’s Spouse: _____________________________________ Date: ___________
I have read the attached Transfer on Death Designation information and by signing my name at the end thereof,
in the presence of a notary public, request that U.S. Energy Development Corporation, upon my death, register
the partnership units designated above in the names of the beneficiaries set forth above.
Signed By:
Dated:
Print Name:
STATE OF
COUNTY OF
)
:ss
)
On the _____day of ____________, in the year _________, before me, the undersigned,
personally appeared ________________________________, personally known to me or proved
to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are)
subscribed to the within instrument and acknowledged to me that he/she/they executed the same
in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the
individual(s), or the person upon behalf of which the individuals(s) acted, executed the
instrument.
_________________
Initials
__________________________________________
Notary Public
Rev. Date: 01/14
TRANSFER ON DEATH DESIGNATION
This is an OPTIONAL form which may be used by individuals (hereinafter sometimes
referred to as “You”) who own partnership units individually or as a tenant in common. This
form may not be used by individuals who own units with one or more other persons as joint
tenants with rights of survivorship or by partnerships, trusts, corporations, or limited liability
companies. If used by such individuals (i.e. You), this form will determine who receives
title/ownership of the units You identify upon Your death. THE USE OF THIS FORM HAS
LEGAL CONSEQUENCES AND YOU SHOULD CONSULT WITH YOUR LEGAL,
FINANCIAL AND TAX ADVISORS BEFORE UTILIZING IT.
To be effective, this Transfer On Death form (“TOD” form) must be received by the
Managing General Partner of the partnerships in which You own units (U.S. Energy
Development Corporation is currently the Managing General Partner). The TOD form will only
apply to the units You identify and not to any other units You may own or subsequently acquire
or to any of Your other assets. If You dispose of any of the identified units before Your death,
the TOD form will no longer apply to those units or to any units You may receive in exchange
for the identified units.
If used, the Managing General Partner will rely on the TOD form as controlling and
accordingly will not consider any provisions of Your will or any applicable laws of intestate
succession (laws which govern the distribution of the assets of persons who die without a will) to
determine who the successor owner of the identified partnership units is, unless a court of
competent jurisdiction orders otherwise.
The designation of a beneficiary or beneficiaries of Your units in the TOD form will not
be affected by a subsequent change in Your relationship with a designated beneficiary (for
example, as a result of a divorce) or a subsequent change in Your status (for example, if You
marry after executing the TOD form), unless a court of competent jurisdiction orders otherwise.
A change of beneficiary must be made by completing a new TOD form. YOU CAN CHANGE
THE BENEFICIARY DESIGNATION AT ANY TIME BY EXECUTING A NEW TOD
FORM (INCLUDING HAVING YOUR SIGNATURE ON THE TOD FORM
ACKNOWLEDGED BY A NOTARY PUBLIC) AND DELIVERING IT TO THE
MANAGING GENERAL PARTNER.
On the TOD form You may designate Your beneficiaries by naming specific individuals
or by identifying a class of beneficiaries, for example, “my children”. In the event You
designate a class of beneficiaries, You must indicate whether the designation is “per stirpes” or
“per capita”. This determines what happens if a member of the class of beneficiaries predeceases
You. For example, if You designate “my children” as the class of beneficiaries, have three
children and one of them predeceases You, survived by two children of his/her own; if You
designate the class as “my children, per capita”, the units would be divided equally between the
two children who survive You or if You designate the class as “my children, per stirpes”, each
-1_________________
059522.00009 Business 12016125v1
Rev. Date: 01/14
Initials
surviving child would receive one-third of the units and the two children of the deceased child
would each receive one-sixth of the units.
If no percentage of ownership for the designated beneficiaries is stated in the TOD form,
it will be assumed that the beneficiaries are to share equally in ownership of the affected units. If
percentages of ownership are stated and those percentages in total either are less than or exceed
100% then ownership will be allocated proportionately with each beneficiary receiving a
percentage equal to the percentage identified for him/her divided by the total of the percentages
listed on the TOD form. The Managing General Partner may round any percentage involved so
that it does not exceed the number of columns to the right of the decimal point that it customarily
uses for such purposes.
If a designated beneficiary, or a member of a class of designated beneficiaries, is a minor,
title to the units may only be placed in the name of an appropriately designated guardian or
custodian for such minor, and such guardian/custodian must be appointed or designated at no
expense to the Managing General Partner.
Any designated beneficiary that is not a natural person must be in existence prior to the
date of Your death, and not as a result of Your death, for the designation to be effective. For
example, the designation in the TOD form of a trust created by Your will, will not be effective.
The transfer of ownership provided for by the TOD form will be effective on the date of
Your death. The Managing General Partner shall have no liability or responsibility for payments
or distributions made prior to such Managing General Partner receiving written proof, acceptable
in form and content to the Managing General Partner, of Your death. The Managing General
Partner shall have no obligation or duty to notify, locate or identify any beneficiary.
If You designate a class of beneficiaries, it shall be the obligation of such beneficiaries to
provide written proof, acceptable in form and content to the Managing General Partner, to such
Managing General Partner, of the identity of the members of such class.
In consideration of the Managing General Partner relying on the TOD form to transfer
ownership of the designated units upon Your death, You, for Yourself, Your heirs, successors
and assigns, including all beneficiaries designated by You in the TOD form, hereby release the
Managing General Partner, its successors and assigns, from any liability, and hereby agree to
indemnify and hold the Managing General Partner, its successors and assigns, harmless from any
liability, cost or expense, arising from or relating to such Managing General Partner’s, or its
successors or assigns, reliance upon the TOD form or from any action or activity by the
Managing General Partner, its successors or assigns, with respect to the TOD form.
By signing this TOD form You are designating the beneficiaries who will receive
ownership of the partnership units You have identified herein and You, for Yourself, Your heirs,
successors and assigns, including the beneficiaries You designate, are agreeing to be bound by
the provisions set forth herein.
-2_________________
059522.00009 Business 12016125v1
Rev. Date: 01/14
Initials