**Instructions for Beneficiary Designation Change Form - SA 4805-GA**

**Retiree Form for Those Retired *PRIOR* *to* January 1, 2007**

*SCROLL DOWN FOR FORM.*

**IMPORTANT: Beneficiary changes will NOT go into effect until signed by
the employee and a witness (non-family/ non-beneficiary), and with the
original returned to the Benefits office (MS-1463).**

1.  Complete the form with your name, social security number,
    beneficiary (ies) and check the appropriate Plan(s).

2.  The witness must be a Non-Family member who will not be receiving
    any of the benefit.

3.  The Plan called "Retirement Income/Pension Security Plan" applies
    only to those employees who were employed with Sandia Laboratories
    prior to 7/1/75 and contributed to the pension plan.

  ----------- -----------------------------------------------------------
  **For       The beneficiary designation on your Basic Group Life
  Retirees    Insurance **G-90373** is a "Qualified Family Member"
  Only:**     defined as a spouse that you have been married to for one
              year or more; a [dependent]{.underline} child; or a
              [dependent]{.underline} parent. If there is no "Qualified
              Family Member," then \$500 is paid to your estate. **THIS
              DESIGNATION CANNOT BE CHANGED and a beneficiary form is not
              needed.**

  ----------- -----------------------------------------------------------

4.  This form applies ONLY to the company paid Basic Supplemental Group
    Life Insurance. If you have VTL (Voluntary Term Life Insurance), a
    beneficiary change form (SF 4400-VTL) is available on the web.
    <http://www.sandia.gov/>

5.  Be sure to make a copy of the beneficiary change forms (and don't
    forget to file a copy of this form with your other legal documents)
    before you return the original to the Benefits Department, MS-1463.

6.  Children under 18 cannot be paid as a beneficiary until the court
    appoints a guardian for financial matters or until the child
    reaches 18. If you still want to include your children, please list
    individually.

7.  Use the word "otherwise" before the name(s) of the contingent
    beneficiary (ies).

8.  A primary beneficiary is the person to whom the death benefits will
    be paid first. You may wish to name contingent beneficiaries who
    will share equally if there is no primary beneficiary or if the
    primary beneficiary is deceased. If the beneficiary or beneficiaries
    you have selected die before you do or if you have not completed a
    beneficiary change form, your insurance will be paid to the first
    eligible recipient(s) in the following order: surviving spouse,
    children, parents, or estate.

![](media/image1.png){width="2.7506944444444446in"
height="0.42986111111111114in"}

**BENEFICIARY DESIGNATION CHANGE FORM**

**RETIREE FORM FOR THOSE RETIRED *PRIOR* *TO* JANUARY 1, 2007**

BENEFITS DEPARTMENT, MS-1463

  ---------- ------------ ----------- --------- -- --------------- ---------------- ----------- --------- ----------- --
                                                   **NAME CHANGE                                                      
                                                   ONLY**                                                             

  NAME       **     **    **     **   **   **      **If you have                                                      
                                                   changed your                                                       
                                                   name, list                                                         
                                                   below the name                                                     
                                                   you used                                                           
                                                   previously:**                                                      

             (Last Name,                                                                                              
             First Name,                                                                                              
             Middle                                                                                                   
             Initial)                                                                                                 

                                                                                                                      

  Social                  **     **                                **     **        **     **             **     **   
  Security                                                                                                            
  Number                                                                                                              

                                                                   Last Name        First Name  Middle                
                                                                                                Initial               
  ---------- ------------ ----------- --------- -- --------------- ---------------- ----------- --------- ----------- --

  ---------------- -------------------------------------------------------------------
  **When changing  
  beneficiaries,   
  please note the  
  following:**     

                   

  1\.              Write the beneficiary's name like this -- Mary A. Doe -- not like
                   this -- Mrs. John Doe

                   

  2\.              If you name a beneficiary who is not a member of your family,
                   please indicate the person's social security number and
                   address**.**

                   

  3\.              Remember that if you name several people as primary (or contingent)
                   beneficiaries, they will share equally unless you specifically
                   indicate differently in the percentage column. Please indicate the
                   percentage you wish to go to each beneficiary.
  ---------------- -------------------------------------------------------------------

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| : |               |         |   |                          |   |         |   |
+---+---------------+---------+---+--------------------------+---+---------+---+
|   | **Primary     |         |   | **Relationship to me**   |   | **%**   |   |
|   | Benef         |         |   |                          |   |         |   |
|   | iciary(ies)** |         |   | **     **                |   | **   ** |   |
|   |               |         |   |                          |   |         |   |
|   | **     **     |         |   |                          |   |         |   |
+---+---------------+---------+---+--------------------------+---+---------+---+
|   |               |         |   |                          |   |         |   |
+---+---------------+---------+---+--------------------------+---+---------+---+
|   | **     **     |         |   | **     **                |   | **   ** |   |
+---+---------------+---------+---+--------------------------+---+---------+---+
|   |               |         |   |                          |   |         |   |
+---+---------------+---------+---+--------------------------+---+---------+---+
|   | **     **     |         |   | **     **                |   | **   ** |   |
+---+---------------+---------+---+--------------------------+---+---------+---+
|   |               |         |   |                          |   |         |   |
+---+---------------+---------+---+--------------------------+---+---------+---+
|   | **     **     |         |   | **     **                |   | **   ** |   |
+---+---------------+---------+---+--------------------------+---+---------+---+
|   |               |         |   |                          |   |         |   |
+---+---------------+---------+---+--------------------------+---+---------+---+
|   | **     **     |         |   | **     **                |   | **   ** |   |
+---+---------------+---------+---+--------------------------+---+---------+---+
|   |               |         |   |                          |   |         |   |
+---+---------------+---------+---+--------------------------+---+---------+---+
|   | **Contingent  |         |   | **Relationship to me**   |   | **%**   |   |
|   | Benef         |         |   |                          |   |         |   |
|   | iciary(ies)** |         |   | **     **                |   | **   ** |   |
|   |               |         |   |                          |   |         |   |
|   | **     **     |         |   |                          |   |         |   |
+---+---------------+---------+---+--------------------------+---+---------+---+
|   |               |         |   |                          |   |         |   |
+---+---------------+---------+---+--------------------------+---+---------+---+
|   | **     **     |         |   | **     **                |   | **   ** |   |
+---+---------------+---------+---+--------------------------+---+---------+---+
|   |               |         |   |                          |   |         |   |
+---+---------------+---------+---+--------------------------+---+---------+---+
|   | **     **     |         |   | **     **                |   | **   ** |   |
+---+---------------+---------+---+--------------------------+---+---------+---+
|   |               |         |   |                          |   |         |   |
+---+---------------+---------+---+--------------------------+---+---------+---+
|   | **     **     |         |   | **     **                |   | **   ** |   |
+---+---------------+---------+---+--------------------------+---+---------+---+
|   |               |         |   |                          |   |         |   |
+---+---------------+---------+---+--------------------------+---+---------+---+
|   | **     **     |         |   | **     **                |   | **   ** |   |
+---+---------------+---------+---+--------------------------+---+---------+---+
|   |               |         |   |                          |   |         |   |
+---+---------------+---------+---+--------------------------+---+---------+---+
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| s |               |         |   |                          |   |         |   |
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| o |               |         |   |                          |   |         |   |
| r |               |         |   |                          |   |         |   |
| m |               |         |   |                          |   |         |   |
| s |               |         |   |                          |   |         |   |
| c |               |         |   |                          |   |         |   |
| a |               |         |   |                          |   |         |   |
| n |               |         |   |                          |   |         |   |
| b |               |         |   |                          |   |         |   |
| e |               |         |   |                          |   |         |   |
| f |               |         |   |                          |   |         |   |
| o |               |         |   |                          |   |         |   |
| u |               |         |   |                          |   |         |   |
| n |               |         |   |                          |   |         |   |
| d |               |         |   |                          |   |         |   |
| o |               |         |   |                          |   |         |   |
| n |               |         |   |                          |   |         |   |
| t |               |         |   |                          |   |         |   |
| h |               |         |   |                          |   |         |   |
| e |               |         |   |                          |   |         |   |
| s |               |         |   |                          |   |         |   |
| a |               |         |   |                          |   |         |   |
| n |               |         |   |                          |   |         |   |
| d |               |         |   |                          |   |         |   |
| i |               |         |   |                          |   |         |   |
| a |               |         |   |                          |   |         |   |
| . |               |         |   |                          |   |         |   |
| g |               |         |   |                          |   |         |   |
| o |               |         |   |                          |   |         |   |
| v |               |         |   |                          |   |         |   |
| w |               |         |   |                          |   |         |   |
| e |               |         |   |                          |   |         |   |
| b |               |         |   |                          |   |         |   |
| s |               |         |   |                          |   |         |   |
| i |               |         |   |                          |   |         |   |
| t |               |         |   |                          |   |         |   |
| e |               |         |   |                          |   |         |   |
| . |               |         |   |                          |   |         |   |
+---+---------------+---------+---+--------------------------+---+---------+---+
|   |               | Basic   |   |                          |   |         |   |
|   |               | Suppl   |   |                          |   |         |   |
|   |               | emental |   |                          |   |         |   |
|   |               | Group   |   |                          |   |         |   |
|   |               | Life    |   |                          |   |         |   |
|   |               | In      |   |                          |   |         |   |
|   |               | surance |   |                          |   |         |   |
+---+---------------+---------+---+--------------------------+---+---------+---+
| I |               |         |   |                          |   |         |   |
| f |               | Contri  |   |                          |   |         |   |
| e |               | butions |   |                          |   |         |   |
| m |               | from    |   |                          |   |         |   |
| p |               | the     |   |                          |   |         |   |
| l |               | Ret     |   |                          |   |         |   |
| o |               | irement |   |                          |   |         |   |
| y |               | Income  |   |                          |   |         |   |
| e |               | Plan or |   |                          |   |         |   |
| d |               | Pension |   |                          |   |         |   |
| b |               | S       |   |                          |   |         |   |
| y |               | ecurity |   |                          |   |         |   |
| S |               | Plan    |   |                          |   |         |   |
| N |               |         |   |                          |   |         |   |
| L |               |         |   |                          |   |         |   |
| p |               |         |   |                          |   |         |   |
| r |               |         |   |                          |   |         |   |
| i |               |         |   |                          |   |         |   |
| o |               |         |   |                          |   |         |   |
| r |               |         |   |                          |   |         |   |
| t |               |         |   |                          |   |         |   |
| o |               |         |   |                          |   |         |   |
| 7 |               |         |   |                          |   |         |   |
| / |               |         |   |                          |   |         |   |
| 1 |               |         |   |                          |   |         |   |
| / |               |         |   |                          |   |         |   |
| 7 |               |         |   |                          |   |         |   |
| 5 |               |         |   |                          |   |         |   |
+---+---------------+---------+---+--------------------------+---+---------+---+

<table style="width:100%;">
<colgroup>
<col style="width: 8%" />
<col style="width: 2%" />
<col style="width: 35%" />
<col style="width: 5%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 18%" />
<col style="width: 3%" />
<col style="width: 7%" />
<col style="width: 3%" />
</colgroup>
<tbody>
<tr class="odd">
<td>Dated at</td>
<td colspan="2"><strong>     </strong></td>
<td>this</td>
<td><strong>     </strong></td>
<td>day of</td>
<td><strong>     </strong></td>
<td>,</td>
<td><strong>     </strong></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">(City, State)</td>
<td></td>
<td>(Day)</td>
<td></td>
<td>(Month)</td>
<td></td>
<td>(Year)</td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td></td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td>Full Signature of Employee</td>
<td></td>
<td colspan="6"><p>Full Signature of Witness</p>
<p>(Non-Relative/ Non-Beneficiary)</p></td>
</tr>
</tbody>
</table>

**Return the original to Benefits Department, Mail Stop 1463**