Exhibit 10.13

 

PLUMAS BANK

DIRECTOR RETIREMENT AGREEMENT

 

 

THIS DIRECTOR RETIREMENT AGREEMENT (the “Agreement”) is adopted this 21st day of
December, 2016, by and between PLUMAS BANK, a California corporation located in
Quincy, California (the “Company”) and Steven M. Coldani (the “Director”).

 

The purpose of this Agreement is to provide specified benefits to the Director
who contributes to the continued growth, development, and future business
success of the Company.

 

Article 1

Definitions

 

Whenever used in this Agreement, the following words and phrases shall have the
meanings specified:

 

1.1

“Accrual Balance” means the liability that should be accrued by the Company,
under Generally Accepted Accounting Principles (“GAAP”), for the Company’s
obligation to the Director under this Agreement, by applying ASC 715
Compensation—Retirement Benefits and the Discount Rate. Any one of a variety of
amortization methods may be used to determine the Accrual Balance. However, once
chosen, the method must be consistently applied. The Accrual Balance shall be
reported annually by the Company to the Director.

 

1.2

“Beneficiary” means each designated person, or the estate of the deceased
Director, entitled to benefits, if any, upon the death of the Director
determined pursuant to Article 4.

 

1.3

“Beneficiary Designation Form” means the form established from time to time by
the Plan Administrator that the Director completes, signs, and returns to the
Plan Administrator to designate one or more Beneficiaries.

 

1.4

“Board” means the Board of Directors of the Company as from time to time
constituted.

 

1.5

“Change in Control” means a change in the ownership or effective control of the
Company, or in the ownership of a substantial portion of the assets of the
Company, as such change is defined in Section 409A of the Code and regulations
thereunder.

 

1.6

“Code” means the Internal Revenue Code of 1986, as amended.

 

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1.7

“Disability” means Director: (i) is unable to engage in any substantial gainful
activity by reason of any medically determinable physical or mental impairment
which can be expected to result in death or can be expected to last for a
continuous period of not less than twelve (12) months; or (ii) is, by reason of
any medically determinable physical or mental impairment which can be expected
to result in death or can be expected to last for a continuous period of not
less than twelve (12) months, receiving income replacement benefits for a period
of not less than three (3) months under an accident and health plan covering
directors of the Company. Medical determination of Disability may be made by
either the Social Security Administration or by the provider of an accident or
health plan covering directors of the Company. Upon the request of the Plan
Administrator, the Director must submit proof to the Plan Administrator of the
Social Security Administration’s or the provider’s determination.

 

1.8

“Discount Rate” means the rate used by the Plan Administrator for determining
the Accrual Balance. The initial Discount Rate is five percent (5%). However,
the Plan Administrator, in its discretion, may adjust the Discount Rate to
maintain the rate within reasonable standards according to GAAP and/or
applicable bank regulatory guidance.

 

1.9

“Effective Date” means November 1, 2016.

 

1.10

“Normal Retirement Age” means the earlier of (i) Director attaining age
sixty-five (65) and completing one-hundred eighty (180) months of Service; or
(ii) the date the Director is required to retire pursuant to the Company’s
mandatory retirement policy for Directors.

 

1.11

“Normal Retirement Date” means the later of Normal Retirement Age or Separation
from Service.

 

1.12

“Plan Administrator” means the plan administrator described in Article 6.

 

1.13

“Plan Year” means each twelve-month period commencing on November 1st and ending
on October 31st of each year. The initial Plan Year shall commence on the
Effective Date of this Agreement and end on the following October 31, 2017.

 

1.14

“Separation from Service” means the termination of the Director’s service as a
director of the Company for reasons other than death.

 

1.15

“Termination for Cause” means Separation from Service for:

 

 

(a)

Gross negligence or gross neglect of duties to the Company; or

 

 

(b)

Conviction of a felony or of a gross misdemeanor involving moral turpitude in
connection with the Director’s service with the Company; or

 

 

(c)

Fraud, disloyalty, dishonesty or willful violation of any law or significant
Company policy committed in connection with the Director's service and resulting
in a material adverse effect on the Company.

 

1.16

“Years of Service” means the twelve consecutive month period beginning on the
date the Director’s service on the Board commences and any twelve (12) month
anniversary thereof, during the entirety of which time the Director is a
director of the Company. Service with a subsidiary or other entity controlled by
the Company before the time such entity became a subsidiary or under such
control shall not be considered “credited service” unless the Plan Administrator
specifically agrees to credit such service. In addition and solely for the
purpose of determining the amount of benefits to be distributed hereunder the
Plan Administrator in its discretion may also grant additional Years of Service
in such circumstances where it deems such additional service appropriate.

 

Article 2

Distributions During Lifetime

2.1

Vested Benefit. The Company shall distribute to the Director the benefit
described in this Section 2.1.

 

2.1.1

Amount of Benefit. The monthly vested benefit under this Section 2.1 is as
follows:

Year ending

Monthly Benefit

10/31/17

 $96.84

10/31/18

$181.71

10/31/19

$262.44

10/31/20

$339.25

10/31/21

$412.31

10/31/22

$481.82

10/31/23

$547.95

10/31/24

$610.86

10/31/25

$670.71

10/31/26

$727.64

10/31/27

$781.80

15 years of Service 11/30/28

$833.33

 

 

 

2.1.2

Distribution of Benefit. The Company shall distribute the vested benefit to the
Director commencing on the first day of the month following the Normal
Retirement Date. The monthly benefit shall be distributed to the Director for
one-hundred eighty (180) months.

 

 

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2.2      Distribution of Benefit – Disability. If the Director experiences a
Disability which results in a Separation from Service prior to the Normal
Retirement Age, the Company shall distribute to the Director the benefit
described in this Section 2.1.1      commencing on the first day of the month
following Separation from Service. The monthly benefit shall be distributed to
the Director for one-hundred eighty (180) months.

 

2.3

Change in Control Benefit. Upon a Change in Control, followed by a Separation
from Service, the Company shall distribute to the Director the benefit described
in this Section 2.3 in lieu of any other benefit under this Article.

 

 

2.3.1

Amount of Benefit. The monthly benefit under this Section 2.3 is $833.33 per
month.

 

 

2.3.2

Distribution of Benefit. The Company shall distribute the monthly benefit to the
Director commencing on the first day of the month following Separation from
Service. The monthly benefit shall be distributed to the Director for
one-hundred eighty (180) months.

 

 

2.3.3

Excess Parachute Payments. Notwithstanding any provision of this Agreement to
the contrary, and to the extent allowed by Code Section 409A, if any
distribution(s) made under this Section 2.3 would be treated as an “excess
parachute payment” under Code Section 280G, the Company shall reduce such
distribution(s) to the extent necessary to avoid treating the distribution(s) as
an excess parachute payment.

 

2.4

Distributions Upon Income Inclusion Under Section 409A of the Code. Upon the
inclusion of any amount into the Director’s income as a result of the failure of
this non-qualified deferred compensation plan to comply with the requirements of
Section 409A of the Code, to the extent such tax liability can be covered by the
Director’s vested Accrual Balance without further to comply with the
requirements of Section 409a of the Code, a distribution shall be made as soon
as is administratively practicable following the discovery of the plan failure.

 

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2.5

Change in Form or Timing of Distributions.  For distribution of benefits under
this Article 2, the Director and the Company may, subject to the terms of
Section 8.1, amend the Agreement to delay the timing or change the form of
distributions.  Any such amendment:

 

 

(a)

may not accelerate the time or schedule of any distribution, except as provided
in Section 409A of the Code and the regulations there under;

 

 

(b)

must, for benefits distributable under Sections 2.1, 2.2 and 2.3, delay the
commencement of distributions for a minimum of five (5) years from the date the
first distribution was originally scheduled to be made; and

 

 

(c)

must take effect not less than twelve (12) months after the amendment is made.

 

 

 

Article 3

Distribution at Death

 

3.1

Death During Active Service. If the Director dies while in the active service of
the Company, the Company shall distribute to the Beneficiary the death benefit
in a lump sum of $30,000 within 30 days of the Director’s death.

 

3.2

Death During Distribution of a Benefit. If the Director dies after any benefit
distributions have commenced under this Agreement but before receiving all such
distributions, the Company shall distribute to the Beneficiary a death benefit
in a lump sum equal to the amount of $30,000 less the aggregate amount of
benefits previously paid pursuant to this Agreement within 30 days of the
Director’s death.

 

3.3

Death After Separation from Service But Before Benefit Distributions Commence.
If the Director is entitled to benefit distributions under this Agreement, but
dies prior to the commencement of said benefit distributions, the Company shall
distribute to the Beneficiary the death benefit in a lump sum of $30,000 within
30 days of the Director’s death.

 

Article 4

Beneficiaries

 

4.1

Beneficiary. The Director shall have the right, at any time, to designate a
Beneficiary to receive any benefit distributions under this Agreement upon the
death of the Director. The Beneficiary designated under this Agreement may be
the same as or different from the beneficiary designated under any other plan of
the Company in which the Director participates.

 

4.2

Beneficiary Designation: Change; Spousal Consent. The Director shall designate a
Beneficiary by completing and signing the Beneficiary Designation Form, and
delivering it to the Plan Administrator or its designated agent. If the Director
names someone other than his or her spouse as a Beneficiary, a spousal consent,
in the form designated by the Plan Administrator, must be signed by the
Director’s spouse and returned to the Plan Administrator. The Director's
beneficiary designation shall be deemed automatically revoked if the Beneficiary
predeceases the Director or if the Director names a spouse as Beneficiary and
the marriage is subsequently dissolved. The Director shall have the right to
change a Beneficiary by completing, signing and otherwise complying with the
terms of the Beneficiary Designation Form and the Plan Administrator’s rules and
procedures, as in effect from time to time. Upon the acceptance by the Plan
Administrator of a new Beneficiary Designation Form, all Beneficiary
designations previously filed shall be cancelled. The Plan Administrator shall
be entitled to rely on the last Beneficiary Designation Form filed by the
Director and accepted by the Plan Administrator prior to the Director’s death.

 

4.3

Acknowledgment. No designation or change in designation of a Beneficiary shall
be effective until received, accepted and acknowledged in writing by the Plan
Administrator or its designated agent.

 

4.4

No Beneficiary Designation. If the Director dies without a valid beneficiary
designation, or if all designated Beneficiaries predecease the Director, then
the Director’s spouse shall be the designated Beneficiary. If the Director has
no surviving spouse, the benefits shall be made to the personal representative
of the Director's estate.

 

4.5

Facility of Distribution. If the Plan Administrator determines in its discretion
that a benefit is to be distributed to a minor, to a person declared
incompetent, or to a person incapable of handling the disposition of that
person’s property, the Plan Administrator may direct distribution of such
benefit to the guardian, legal representative or person having the care or
custody of such minor, incompetent person or incapable person. The Plan
Administrator may require proof of incompetence, minority or guardianship as it
may deem appropriate prior to distribution of the benefit. Any distribution of a
benefit shall be a distribution for the account of the Director and the
Director’s Beneficiary, as the case may be, and shall be a complete discharge of
any liability under the Agreement for such distribution amount.

 

Article 5

General Limitations

 

5.1

Termination for Cause. Notwithstanding any provision of this Agreement to the
contrary, the Company shall not distribute any benefit under this Agreement if
the Director’s service with the Company is terminated due to a Termination for
Cause.

 

 

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5.2

Suicide or Misstatement. No benefits shall be distributed if the Director
commits suicide within two years after the Effective Date of this Agreement, or
if an insurance company which issued a life insurance policy covering the
Director and owned by the Company denies coverage (i) for material misstatements
of fact made by the Director on an application for such life insurance, or (ii)
for any other reason.

 

5.3

Removal. Notwithstanding any provision of this Agreement to the contrary, the
Company shall not distribute any benefit under this Agreement if the Director is
subject to a final removal or prohibition order issued by an appropriate federal
banking agency pursuant to Section 8(e) of the Federal Deposit Insurance Act.

 

Article 6

Administration of Agreement

 

6.1

Plan Administrator Duties. This Agreement shall be administered by a Plan
Administrator which shall consist of the Board, or such committee or person(s)
as the Board shall appoint. The Plan Administrator shall administer this
Agreement according to its express terms and shall also have the discretion and
authority to (i) make, amend, interpret and enforce all appropriate rules and
regulations for the administration of this Agreement and (ii) decide or resolve
any and all questions including interpretations of this Agreement, as may arise
in connection with the Agreement to the extent the exercise of such discretion
and authority does not conflict with Section 409A of the Code and regulations
thereunder.

 

6.2

Agents. In the administration of this Agreement, the Plan Administrator may
employ agents and delegate to them such administrative duties as it sees fit,
(including acting through a duly appointed representative), and may from time to
time consult with counsel who may be counsel to the Company.

 

6.3

Binding Effect of Decisions. The decision or action of the Plan Administrator
with respect to any question arising out of or in connection with the
administration, interpretation and application of the Agreement and the rules
and regulations promulgated hereunder shall be final and conclusive and binding
upon all persons having any interest in the Agreement.

 

6.4

Indemnity of Plan Administrator. The Company shall indemnify and hold harmless
the members of the Plan Administrator against any and all claims, losses,
damages, expenses or liabilities arising from any action or failure to act with
respect to this Agreement, except in the case of willful misconduct by the Plan
Administrator or any of its members.

 

6.5

Company Information. To enable the Plan Administrator to perform its functions,
the Company shall supply full and timely information to the Plan Administrator
on all matters relating to the date and circumstances of the retirement,
Disability, death, or Separation from Service of the Director, and such other
pertinent information as the Plan Administrator may reasonably require.

 

6.6

Annual Statement. The Plan Administrator shall provide to the Director, within
one hundred twenty (120) days after the end of each Plan Year, a statement
setting forth the benefits to be distributed under this Agreement.

 

Article 7

Claims And Review Procedures

 

7.1

Claims Procedure. A Director or Beneficiary (“claimant”) who has not received
benefits under the Agreement that he or she believes should be distributed shall
make a claim for such benefits as follows:

 

 

7.1.1

Initiation – Written Claim. The claimant initiates a claim by submitting to the
Plan Administrator a written claim for the benefits. If such a claim relates to
the contents of a notice received by the claimant, the claim must be made within
sixty (60) days after such notice was received by the claimant. All other claims
must be made within one hundred eighty (180) days of the date on which the event
that caused the claim to arise occurred. The claim must state with particularity
the determination desired by the claimant.

 

 

 

7.1.2

Timing of Plan Administrator Response. The Plan Administrator shall respond to
such claimant within 90 days after receiving the claim. If the Plan
Administrator determines that special circumstances require additional time for
processing the claim, the Plan Administrator can extend the response period by
an additional 90 days by notifying the claimant in writing, prior to the end of
the initial 90-day period, that an additional period is required. The notice of
extension must set forth the special circumstances and the date by which the
Plan Administrator expects to render its decision.

 

 

7.1.3

Notice of Decision. If the Plan Administrator denies part or all of the claim,
the Plan Administrator shall notify the claimant in writing of such denial. The
Plan Administrator shall write the notification in a manner calculated to be
understood by the claimant. The notification shall set forth:

 

 

(a)

The specific reasons for the denial;

 

 

(b)

A reference to the specific provisions of the Agreement on which the denial is
based;

 

 

(c)

A description of any additional information or material necessary for the
claimant to perfect the claim and an explanation of why it is needed; and

 

 

(d)

An explanation of the Agreement’s review procedures and the time limits
applicable to such procedures.

 

7.2

Review Procedure. If the Plan Administrator denies part or all of the claim, the
claimant shall have the opportunity for a full and fair review by the Plan
Administrator of the denial, as follows:

 

 

7.2.1

Initiation – Written Request. To initiate the review, the claimant, within 60
days after receiving the Plan Administrator’s notice of denial, must file with
the Plan Administrator a written request for review.

 

 

7.2.2

Additional Submissions – Information Access. The claimant shall then have the
opportunity to submit written comments, documents, records and other information
relating to the claim. The Plan Administrator shall also provide the claimant,
upon request and free of charge, reasonable access to, and copies of, all
documents, records and other information relevant to the claimant’s claim for
benefits.

 

 

7.2.3

Considerations on Review. In considering the review, the Plan Administrator
shall take into account all materials and information the claimant submits
relating to the claim, without regard to whether such information was submitted
or considered in the initial benefit determination.

 

 

7.2.4

Timing of Plan Administrator Response. The Plan Administrator shall respond in
writing to such claimant within 60 days after receiving the request for review.
If the Plan Administrator determines that special circumstances require
additional time for processing the claim, the Plan Administrator can extend the
response period by an additional 60 days by notifying the claimant in writing,
prior to the end of the initial 60-day period, that an additional period is
required. The notice of extension must set forth the special circumstances and
the date by which the Plan Administrator expects to render its decision.

 

 

7.2.5

Notice of Decision. The Plan Administrator shall notify the claimant in writing
of its decision on review. The Plan Administrator shall write the notification
in a manner calculated to be understood by the claimant. The notification shall
set forth:

 

 

(a)

The specific reasons for the denial;

 

 

(b)

A reference to the specific provisions of the Agreement on which the denial is
based;

 

 

(c)

A statement that the claimant is entitled to receive, upon request and free of
charge, reasonable access to, and copies of, all documents, records and other
information relevant to the claimant’s claim for benefits; and

 

 

(d)

A statement of the claimant’s right to bring a civil action.

 

Article 8

Amendments and Termination

 

8.1

Amendments. This Agreement may be amended only by a written agreement signed by
the Company and the Director. However, the Company may unilaterally amend this
Agreement to conform with written directives to the Company from its auditors or
banking regulators or to comply with legislative or tax law, including without
limitation Section 409A of the Code and any and all regulations and guidance
promulgated thereunder.

 

8.2

Plan Termination Generally. This Agreement may be terminated only by a written
agreement signed by the Company and Director. However, the Company may
unilaterally terminate this Agreement to conform with written directives to the
Company from its auditors or banking regulators or to comply with legislative or
tax law, including without limitation Section 409A of the Code and any and all
regulations and guidance promulgated there under. In the event the Company
unilaterally terminates this Agreement, the Director shall be entitled to
receive from the Company an amount equal to the Accrual Balance as of the date
the Agreement is terminated. Except as provided in Section 8.3, the termination
of this Agreement shall not cause any early distribution of benefits under this
Agreement. Rather, upon such termination, benefit distributions will be made in
accordance with the distribution schedules set forth under Article 2 or Article
3, as applicable.

 

8.3

Plan Terminations Under Section 409A. Notwithstanding anything to the contrary
in Section 8.2, if the Company terminates this Agreement in the following
circumstances:

 

(a)     Within thirty (30) days before, or twelve (12) months after a Change in
Control, provided that all distributions are made no later than twelve (12)
months following such termination of the Agreement and further provided that
all the Company’s arrangements which are substantially similar to the Agreement
are terminated so the Director and all participants in the similar arrangements
are required to receive all amounts of compensation deferred under the
terminated arrangements within twelve (12) months of the termination of the
arrangements;

 

 

(b)

Upon the Company’s dissolution or with the approval of a bankruptcy court
provided that the amounts deferred under the Agreement are included in the
Director's gross income in the latest of (i) the calendar year in which the
Agreement terminates; (ii) the calendar year in which the amount is no longer
subject to a substantial risk of forfeiture; or (iii) the first calendar year in
which the distribution is administratively practical; or

 

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(c)

Upon the Company’s termination of this and all other non-account balance plans
(as referenced in Section 409A of the Code or the regulations thereunder),
provided that all distributions are made no earlier than twelve (12) months and
no later than twenty-four (24) months following such termination, and the
Company does not adopt any new non-account balance plans for a minimum of five
(5) years following the date of such termination;

 

The Company shall distribute the Accrual Balance, determined as of the date of
the termination of the Agreement, to the Director in a lump sum subject to the
above terms.

 

Article 9

Miscellaneous

 

9.1

Binding Effect. This Agreement shall bind the Director and the Company, and
their beneficiaries, survivors, executors, administrators and transferees.

 

9.2

No Guarantee of Service. This Agreement is not a contract for service. It does
not give the Director the right to remain as a director of the Company, nor does
it interfere with the Company’s right to discharge the Director. It also does
not require the Director to remain a director nor interfere with the Director's
right to terminate service at any time.

 

9.3

Non-Transferability. Benefits under this Agreement cannot be sold, transferred,
assigned, pledged, attached or encumbered in any manner.

 

9.4

Tax Withholding and Reporting. The Company shall withhold any taxes that are
required to be withheld, including but not limited to taxes owed under Section
409A of the Code and regulations thereunder, from the benefits provided under
this Agreement. The Director acknowledges that the Company’s sole liability
regarding taxes is to forward any amounts withheld to the appropriate taxing
authority(ies). Further, the Company shall satisfy all applicable reporting
requirements, including those under Section 409A of the Code and regulations
thereunder.

 

9.5

Applicable Law. The Agreement and all rights hereunder shall be governed by the
laws of the State of California, except to the extent preempted by the laws of
the United States of America.

 

9.6

Unfunded Arrangement. The Director and the Beneficiary are general unsecured
creditors of the Company for the distribution of benefits under this Agreement.
The benefits represent the mere promise by the Company to distribute such
benefits. The rights to benefits are not subject in any manner to anticipation,
alienation, sale, transfer, assignment, pledge, encumbrance, attachment, or
garnishment by creditors. Any insurance on the Director's life or other informal
funding asset is a general asset of the Company to which the Director and
Beneficiary have no preferred or secured claim.

 

9.7

Reorganization. The Company shall not merge or consolidate into or with another
bank, or reorganize, or sell substantially all of its assets to another bank,
firm, or person unless such succeeding or continuing bank, firm, or person
agrees to assume and discharge the obligations of the Company under this
Agreement. Upon the occurrence of such event, the term “Company” as used in this
Agreement shall be deemed to refer to the successor or survivor bank.

 

9.8

Entire Agreement. This Agreement constitutes the entire agreement between the
Company and the Director as to the subject matter hereof. No rights are granted
to the Director by virtue of this Agreement other than those specifically set
forth herein.

 

9.9

Interpretation. Wherever the fulfillment of the intent and purpose of this
Agreement requires, and the context will permit, the use of the masculine gender
includes the feminine and use of the singular includes the plural.

 

9.10

Alternative Action. In the event it shall become impossible for the Company or
the Plan Administrator to perform any act required by this Agreement, the
Company or Plan Administrator may in its discretion perform such alternative act
as most nearly carries out the intent and purpose of this Agreement and is in
the best interests of the Company, provided that such alternative acts do not
violate Section 409A of the Code.

 

9.11

Headings. Article and section headings are for convenient reference only and
shall not control or affect the meaning or construction of any of its
provisions.

 

9.12

Validity. In case any provision of this Agreement shall be illegal or invalid
for any reason, said illegality or invalidity shall not affect the remaining
parts hereof, but this Agreement shall be construed and enforced as if such
illegal and invalid provision has never been inserted herein.

 

9.13

Notice. Any notice or filing required or permitted to be given to the Company or
Plan Administrator under this Agreement shall be sufficient if in writing and
hand-delivered, or sent by registered or certified mail, to the address below:

 

Plumas Bank

35 South Lindan Avenue

Quincy, CA 95971

 

Such notice shall be deemed given as of the date of delivery or, if delivery is
made by mail, as of the date shown on the postmark on the receipt for
registration or certification.

 

Any notice or filing required or permitted to be given to the Director under
this Agreement shall be sufficient if in writing and hand-delivered, or sent by
mail, to the last known address of the Director.

 

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9.14

Compliance with Section 409A. This Agreement shall at all times be administered
and the provisions of this Agreement shall be interpreted consistent with the
requirements of Section 409A of the Code and any and all regulations thereunder,
including such regulations as may be promulgated after the Effective Date of
this Agreement.

 

IN WITNESS WHEREOF, the Director and a duly authorized representative of the
Company have signed this Agreement.

 

DIRECTOR:          COMPANY:

PLUMAS BANK

 

/s/ Steven M. Coldani

By _/s/ Andrew J. Ryback

Steven M. Coldani          

Title CEO

{ }     New Designation     

{ }     Change in Designation

 

I, Steven M. Coldani, designate the following as Beneficiary under the
Agreement:

 

Primary:

___________________________________________________________

 

___________________________________________________________

 

_____%

 

_____%

Contingent:

___________________________________________________________

 

___________________________________________________________

 

_____%

 

_____%

Notes:

 

●

Please PRINT CLEARLY or TYPE the names of the beneficiaries.

 

●

To name a trust as Beneficiary, please provide the name of the trustee(s) and
the exact name and date of the trust agreement.

 

●

To name your estate as Beneficiary, please write “Estate of [your name]”.

 

●

Be aware that none of the contingent beneficiaries will receive anything unless
ALL of the primary beneficiaries predecease you.

 

I understand that I may change these beneficiary designations by delivering a
new written designation to the Plan Administrator, which shall be effective only
upon receipt and acknowledgment by the Plan Administrator prior to my death. I
further understand that the designations will be automatically revoked if the
Beneficiary predeceases me, or, if I have named my spouse as Beneficiary and our
marriage is subsequently dissolved.

 

Name:          _______________________________

 

Signature:     _______________________________     Date:     _______

 

SPOUSAL CONSENT (Required if someone other than Spouse named beneficiary):

 

I consent to the beneficiary designation above, and acknowledge that if I am
named Beneficiary and our marriage is subsequently dissolved, the designation
will be automatically revoked.

 

Spouse Name:     _______________________________

 

Signature:     _______________________________     Date:     _______

 

 

Received by the Plan Administrator this ________ day of ___________________,
2___

 

By:     _________________________________

Title:     _________________________________