**Instructions for Beneficiary Designation Change Form**

**SF 4805-PGT**

**For Use by Current Employees and Those who Retire After December 31,
2006**

*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, Sandia Employee 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 by Sandia Laboratories
    prior to 7/1/75 and contributed to the pension plan.

4.  Please check the internal web under **"**[Benefits
    Summary](https://ws26snlnt-new.sandia.gov/psp/pspr1eux/EMPLOYEE/HRMS/c/W3EB_MENU.W3EB_GRID.GBL?NAVSTACK=Clear&PORTALPARAM_PTCNAV=HC_W3EB_GRID_GBL&EOPP.SCNode=HRMS&EOPP.SCPortal=EMPLOYEE&EOPP.SCName=CO_EMPLOYEE_SELF_SERVICE&EOPP.SCLabel=HR Self-Service&EOPP.SCPTfn)"
    or HR Self Service/Benefits/Benefits Summary for a list of your
    current coverage's.

```{=html}
<!-- -->
```
A.  This form applies ONLY to the company paid Sandia Primary Group Term
    Life Insurance.

B.  If you have VTL (Voluntary Term Life Insurance), a beneficiary
    change form ([SF
    4400-VTL](http://www-irn.sandia.gov/corpdata/corpforms/4400vtl.dot))
    is available on the web.

```{=html}
<!-- -->
```
5.  Be sure to make a copy of the beneficiary change forms (and do not
    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 SF 4805-PGT**

**For Use by Current Employees and Those Who Retire After December 31,
2006**

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)                                                                                                 

                                                                                                                      

  Sandia                  **     **                                **     **        **     **             **     **   
  Employee                                                                                                            
  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.
  ---------------- -------------------------------------------------------------------

+---+-------------------------+---+--------------------------+---+---------+---+
| I |                         |   |                          |   |         |   |
| h |                         |   |                          |   |         |   |
| e |                         |   |                          |   |         |   |
| r |                         |   |                          |   |         |   |
| e |                         |   |                          |   |         |   |
| b |                         |   |                          |   |         |   |
| y |                         |   |                          |   |         |   |
| r |                         |   |                          |   |         |   |
| e |                         |   |                          |   |         |   |
| v |                         |   |                          |   |         |   |
| o |                         |   |                          |   |         |   |
| k |                         |   |                          |   |         |   |
| e |                         |   |                          |   |         |   |
| a |                         |   |                          |   |         |   |
| n |                         |   |                          |   |         |   |
| y |                         |   |                          |   |         |   |
| p |                         |   |                          |   |         |   |
| r |                         |   |                          |   |         |   |
| e |                         |   |                          |   |         |   |
| v |                         |   |                          |   |         |   |
| i |                         |   |                          |   |         |   |
| o |                         |   |                          |   |         |   |
| u |                         |   |                          |   |         |   |
| s |                         |   |                          |   |         |   |
| l |                         |   |                          |   |         |   |
| y |                         |   |                          |   |         |   |
| m |                         |   |                          |   |         |   |
| a |                         |   |                          |   |         |   |
| d |                         |   |                          |   |         |   |
| e |                         |   |                          |   |         |   |
| d |                         |   |                          |   |         |   |
| e |                         |   |                          |   |         |   |
| s |                         |   |                          |   |         |   |
| i |                         |   |                          |   |         |   |
| g |                         |   |                          |   |         |   |
| n |                         |   |                          |   |         |   |
| a |                         |   |                          |   |         |   |
| t |                         |   |                          |   |         |   |
| i |                         |   |                          |   |         |   |
| o |                         |   |                          |   |         |   |
| n |                         |   |                          |   |         |   |
| s |                         |   |                          |   |         |   |
| o |                         |   |                          |   |         |   |
| f |                         |   |                          |   |         |   |
| P |                         |   |                          |   |         |   |
| r |                         |   |                          |   |         |   |
| i |                         |   |                          |   |         |   |
| m |                         |   |                          |   |         |   |
| a |                         |   |                          |   |         |   |
| r |                         |   |                          |   |         |   |
| y |                         |   |                          |   |         |   |
| a |                         |   |                          |   |         |   |
| n |                         |   |                          |   |         |   |
| d |                         |   |                          |   |         |   |
| / |                         |   |                          |   |         |   |
| o |                         |   |                          |   |         |   |
| r |                         |   |                          |   |         |   |
| c |                         |   |                          |   |         |   |
| o |                         |   |                          |   |         |   |
| n |                         |   |                          |   |         |   |
| t |                         |   |                          |   |         |   |
| i |                         |   |                          |   |         |   |
| n |                         |   |                          |   |         |   |
| g |                         |   |                          |   |         |   |
| e |                         |   |                          |   |         |   |
| n |                         |   |                          |   |         |   |
| t |                         |   |                          |   |         |   |
| b |                         |   |                          |   |         |   |
| e |                         |   |                          |   |         |   |
| n |                         |   |                          |   |         |   |
| e |                         |   |                          |   |         |   |
| f |                         |   |                          |   |         |   |
| i |                         |   |                          |   |         |   |
| c |                         |   |                          |   |         |   |
| i |                         |   |                          |   |         |   |
| a |                         |   |                          |   |         |   |
| r |                         |   |                          |   |         |   |
| y |                         |   |                          |   |         |   |
| ( |                         |   |                          |   |         |   |
| i |                         |   |                          |   |         |   |
| e |                         |   |                          |   |         |   |
| s |                         |   |                          |   |         |   |
| ) |                         |   |                          |   |         |   |
| a |                         |   |                          |   |         |   |
| n |                         |   |                          |   |         |   |
| d |                         |   |                          |   |         |   |
| d |                         |   |                          |   |         |   |
| o |                         |   |                          |   |         |   |
| n |                         |   |                          |   |         |   |
| o |                         |   |                          |   |         |   |
| w |                         |   |                          |   |         |   |
| d |                         |   |                          |   |         |   |
| e |                         |   |                          |   |         |   |
| s |                         |   |                          |   |         |   |
| i |                         |   |                          |   |         |   |
| g |                         |   |                          |   |         |   |
| n |                         |   |                          |   |         |   |
| a |                         |   |                          |   |         |   |
| t |                         |   |                          |   |         |   |
| e |                         |   |                          |   |         |   |
| a |                         |   |                          |   |         |   |
| s |                         |   |                          |   |         |   |
| m |                         |   |                          |   |         |   |
| y |                         |   |                          |   |         |   |
| p |                         |   |                          |   |         |   |
| r |                         |   |                          |   |         |   |
| i |                         |   |                          |   |         |   |
| m |                         |   |                          |   |         |   |
| a |                         |   |                          |   |         |   |
| r |                         |   |                          |   |         |   |
| y |                         |   |                          |   |         |   |
| a |                         |   |                          |   |         |   |
| n |                         |   |                          |   |         |   |
| d |                         |   |                          |   |         |   |
| c |                         |   |                          |   |         |   |
| o |                         |   |                          |   |         |   |
| n |                         |   |                          |   |         |   |
| t |                         |   |                          |   |         |   |
| i |                         |   |                          |   |         |   |
| n |                         |   |                          |   |         |   |
| g |                         |   |                          |   |         |   |
| e |                         |   |                          |   |         |   |
| n |                         |   |                          |   |         |   |
| t |                         |   |                          |   |         |   |
| b |                         |   |                          |   |         |   |
| e |                         |   |                          |   |         |   |
| n |                         |   |                          |   |         |   |
| e |                         |   |                          |   |         |   |
| f |                         |   |                          |   |         |   |
| i |                         |   |                          |   |         |   |
| c |                         |   |                          |   |         |   |
| i |                         |   |                          |   |         |   |
| a |                         |   |                          |   |         |   |
| r |                         |   |                          |   |         |   |
| y |                         |   |                          |   |         |   |
| ( |                         |   |                          |   |         |   |
| i |                         |   |                          |   |         |   |
| e |                         |   |                          |   |         |   |
| s |                         |   |                          |   |         |   |
| ) |                         |   |                          |   |         |   |
| , |                         |   |                          |   |         |   |
| t |                         |   |                          |   |         |   |
| h |                         |   |                          |   |         |   |
| e |                         |   |                          |   |         |   |
| f |                         |   |                          |   |         |   |
| o |                         |   |                          |   |         |   |
| l |                         |   |                          |   |         |   |
| l |                         |   |                          |   |         |   |
| o |                         |   |                          |   |         |   |
| w |                         |   |                          |   |         |   |
| i |                         |   |                          |   |         |   |
| n |                         |   |                          |   |         |   |
| g |                         |   |                          |   |         |   |
| n |                         |   |                          |   |         |   |
| a |                         |   |                          |   |         |   |
| m |                         |   |                          |   |         |   |
| e |                         |   |                          |   |         |   |
| d |                         |   |                          |   |         |   |
| i |                         |   |                          |   |         |   |
| n |                         |   |                          |   |         |   |
| d |                         |   |                          |   |         |   |
| i |                         |   |                          |   |         |   |
| v |                         |   |                          |   |         |   |
| i |                         |   |                          |   |         |   |
| d |                         |   |                          |   |         |   |
| u |                         |   |                          |   |         |   |
| a |                         |   |                          |   |         |   |
| l |                         |   |                          |   |         |   |
| s |                         |   |                          |   |         |   |
| : |                         |   |                          |   |         |   |
+---+-------------------------+---+--------------------------+---+---------+---+
|   | **Primary               |   | **Relationship to me**   |   | **%**   |   |
|   | Beneficiary(ies)**      |   |                          |   |         |   |
|   |                         |   | **     **                |   | **   ** |   |
|   | **     **               |   |                          |   |         |   |
+---+-------------------------+---+--------------------------+---+---------+---+
|   |                         |   |                          |   |         |   |
+---+-------------------------+---+--------------------------+---+---------+---+
|   | **     **               |   | **     **                |   | **   ** |   |
+---+-------------------------+---+--------------------------+---+---------+---+
|   |                         |   |                          |   |         |   |
+---+-------------------------+---+--------------------------+---+---------+---+
|   | **     **               |   | **     **                |   | **   ** |   |
+---+-------------------------+---+--------------------------+---+---------+---+
|   |                         |   |                          |   |         |   |
+---+-------------------------+---+--------------------------+---+---------+---+
|   | **     **               |   | **     **                |   | **   ** |   |
+---+-------------------------+---+--------------------------+---+---------+---+
|   |                         |   |                          |   |         |   |
+---+-------------------------+---+--------------------------+---+---------+---+
|   | **     **               |   | **     **                |   | **   ** |   |
+---+-------------------------+---+--------------------------+---+---------+---+
|   |                         |   |                          |   |         |   |
+---+-------------------------+---+--------------------------+---+---------+---+
|   | **Contingent            |   | **Relationship to me**   |   | **%**   |   |
|   | Beneficiary(ies)**      |   |                          |   |         |   |
|   |                         |   | **     **                |   | **   ** |   |
|   | **     **               |   |                          |   |         |   |
+---+-------------------------+---+--------------------------+---+---------+---+
|   |                         |   |                          |   |         |   |
+---+-------------------------+---+--------------------------+---+---------+---+
|   | **     **               |   | **     **                |   | **   ** |   |
+---+-------------------------+---+--------------------------+---+---------+---+
|   |                         |   |                          |   |         |   |
+---+-------------------------+---+--------------------------+---+---------+---+
|   | **     **               |   | **     **                |   | **   ** |   |
+---+-------------------------+---+--------------------------+---+---------+---+
|   |                         |   |                          |   |         |   |
+---+-------------------------+---+--------------------------+---+---------+---+
|   | **     **               |   | **     **                |   | **   ** |   |
+---+-------------------------+---+--------------------------+---+---------+---+
|   |                         |   |                          |   |         |   |
+---+-------------------------+---+--------------------------+---+---------+---+
|   | **     **               |   | **     **                |   | **   ** |   |
+---+-------------------------+---+--------------------------+---+---------+---+

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

  Please indicate below to which plans the beneficiary designations made
  above apply. If you wish to make a common change to both plans, shown
  below, mark each plan to which the change applies. If you wish to make one
  change to one plan and a different change to another plan, request
  additional forms. Forms can be found on the sandia website. [**(BENEFITS
  FORMS)**](http://www-irn.sandia.gov/corpdata/corpforms/benefitsforms.htm)
  ---------------------------------------------------------------------------

  ------------------ ----------------------------------------------------
                     Sandia Primary Group Term Life Insurance

  If employed @ SNL  Contributions from the Retirement Income Plan or
  prior to 7/1/75    Pension Security Plan
  ------------------ ----------------------------------------------------

<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**