OLD HARBOR NATIVE CORPORATION SETTLEMENT TRUST
SHAREHOLDER BURIAL ASSISTANCE BENEFICIARY DESIGNATION FORM
Name
SSN
Address
Date of Birth
City
State
Phone
Cell
Zip Code
Email
The undersigned hereby revokes any beneficiary designation or direction of payment previously made in respect to proceeds payable
under the Old Harbor Native Corporation Settlement Trust Shareholder Burial Assistance Benefit Program and directs that such
proceeds be paid to:
1. PRIMARY BENEFICIARY OF BURIAL ASSISTANCE. Designate the person you want to receive this
burial assistance benefit who will pay for your funeral/estate expenses (cannot be a minor child):
First, MI, Last, Name
of beneficiary
Relationship
Address
Date of Birth
Percentage or Fraction
designated
100 %
After all funeral expenses are paid, designate whom you wish to receive the balance of any funds left over:
First , MI, Last name
of secondary beneficiary
Address
Percentage or fraction
designated
Relationship
2. SECONDARY BENEFICIARY OF BURIAL ASSISTANCE BENEFIT: In the event of the Primary
Beneficiary is no longer alive, unwilling or unable to receive the burial assistance benefit, designate an
alternate you wish to receive this burial assistance benefit (cannot be minor child):
First , MI, Last name
of secondary beneficiary
Address
Relationship
Percentage or fraction
designated
100 %
After all funeral expenses are paid, designate whom you wish to receive the balance of any funds left over:
First , MI, Last name
of secondary beneficiary
Address
Relationship
Percentage or fraction
designated
If no beneficiary is selected or no beneficiary is alive at the time of the shareholder's death, the shareholder's Estate will be the
default beneficiary. The Provisions on the back of this form are hereby made a part of this beneficiary designation.
Dated at
this
City / State
day of
Date
By:
Month
, 20
Year
By:
Shareholder Signature
Page 1 of 2
(OVER)
Witness (Other Than Named Beneficiary)
Instructions
This form provides for two classes of beneficiaries - Primary and Secondary - but it is not necessary to
designate beneficiaries in both classes. Phrases such as "if living", and "share and share alike" or "equally" are
not necessary as these are covered by the form. The signer should initial any corrections to this form.
Additional Provisions Relating To Beneficiary Designation
For the purpose of this beneficiary designation, "shareholder" means the individual upon whose death the
proceeds are payable.
If the beneficiary designated is the trustee of an Inter Vivos (Living) Trust, and if Old Harbor Native
Corporation Settlement Trust receives proof satisfactory to it that the trust is not in effect when any death
benefit is payable, the Old Harbor Native Corporation Settlement Trust will pay the death benefit as if the trust
beneficiary had died before the shareholder. If the beneficiary designated is the trustee of a Testamentary
Trust, it will be deemed to be the trust which is created under a Last Will and Testament and if, when the death
benefit is payable, it is found that the Last Will and Testament contains no trust or is not admitted to Probate or
the shareholder died intestate, then Old Harbor Native Corporation Settlement Trust will pay the death benefit
as if the trust beneficiary died before the shareholder.
Beneficiary Classification. Unless otherwise specified, beneficiaries in the same class (for example,
"children") will share equally in any death benefit payable to them. If proceeds are payable in unequal shares,
express the shares as a percentage of the proceeds payable, in the space provided. If a beneficiary dies after the
shareholder, but before the benefit is payable, his or her share will be allocated equally among any surviving
beneficiaries in the same class.
Payment to Beneficiaries. Old Harbor Native Corporation Settlement Trust will pay the death benefit as
follows:
(1)
(2)
(3)
(4)
To any Primary beneficiaries who are alive when a payment is due on a prorata basis;
or
If no Primary beneficiary is then alive, to any Secondary beneficiaries who are then alive on a
prorata basis;
or
If no beneficiary is then alive or designated, proceeds will be paid to the shareholder's Estate.
If percentages identified in the Primary or Secondary beneficiary designations do not equal
100%, the percentages, if any, will be applied on a prorata basis. Where no percentages are
identified beneficiaries will
share equally.
RETURN TO:
Old Harbor Native Corporation
2702 Denali Street Suite 100
Anchorage, Alaska 99503
Phone: (907) 278-6100
Fax: (907) 276-3441
Email: [email protected]
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