Kent Supplemental Retirement Plan



 Exhibit 10.11 
 Ameriana Bank, SB 
 Supplemental Retirement Plan 
  
 AMERIANA BANK, SB 
 SUPPLEMENTAL RETIREMENT PLAN 
 THIS SUPPLEMENTAL RETIREMENT PLAN (this “Agreement”) is adopted this 10th day of December, 2008, by and between AMERIANA BANK, SB, a state chartered savings bank located in New Castle, Indiana (the “Bank”), and Michael E.
Kent (the “Director”). 
 The purpose of this Agreement is to provide specified benefits to the Director, a member of a select
group who contributes materially to the continued growth, development and future business success of the Bank. 
 Article 1 

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

	1.1	“Account Value” means the amount shown on Schedule A under the heading Account Value. The parties expressly acknowledge that the Account Value may be different than
the liability that should be accrued by the Bank, under Generally Accepted Accounting Principles (“GAAP”), for the Bank’s obligations under this Agreement. The Account Value on any date other than the end of a Plan Year shall be
determined by adding the prorated increase attributable for the current Plan Year to the Account Value for the previous Plan Year. 

  

	1.2	“Beneficiary” means each designated person or entity, or the estate of the deceased Director, entitled to any benefits upon the death of the Director 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 Bank as from time to time constituted. 

  

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

  

	1.6	“Code” means the Internal Revenue Code of 1986 as amended from time to time. 

  

	1.7	“Early Termination” means Separation from Service before attainment of Normal Retirement Age except when such Separation from Service occurs within twenty-four
(24) months following a Change in Control or due to death. 









 Ameriana Bank, SB 
 Supplemental Retirement Plan 
  
  


	1.8	“Effective Date” means January 1, 2008. 

  

	1.9	“Holding Company” means AMERIANA BANCORP. 

  

	1.10	“Normal Retirement Age” means the Director’s age seventy (70). 

  

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

  

	1.12	“Plan Administrator” means the Board or such committee or person as the Board shall appoint. 

  

	1.13	“Plan Year” means each twelve (12) month period commencing on January 1 and ending on December 31 of each year. The initial Plan Year shall commence
on the Effective Date of this Agreement and end on the following December 31. 

  

	1.14	“Schedule A” means the schedule attached to this Agreement and made a part hereof. Schedule A shall be updated upon a change in any of the benefits under Articles 2
or 3. 

  

	1.15	“Separation from Service” means termination of the Director’s service with the Bank for reasons other than death. Whether a Separation from Service has
occurred is determined in accordance with the requirements of Code Section 409A based on whether the facts and circumstances indicate that the Bank and Director reasonably anticipated that no further services would be performed after a certain
date or that the level of bona fide services the Director would perform after such date (whether as an employee or as an independent contractor) would permanently decrease to no more than twenty percent (20%) of the average level of bona fide
services performed (whether as an employee or an independent contractor) over the immediately preceding thirty-six (36) month period (or the full period of services to the Bank if the Director has been providing services to the Bank less than
thirty-six (36) months). 

 Article 2 
 Distributions During Lifetime 
  

	2.1	Normal Retirement Benefit. Upon Separation from Service after attaining Normal Retirement Age, the Bank shall distribute to the Director the benefit described in this
Section 2.1 in lieu of any other benefit under this Article. 

  

	 	2.1.1	Amount of Benefit. The annual benefit under this Section 2.1 is Twenty Thousand Dollars ($20,000). 

  

	 	2.1.2	Distribution of Benefit. The Bank shall distribute the annual benefit to the Director in twelve (12) equal monthly installments commencing on the first day of the month
following Separation from Service. The annual benefit shall be distributed to the Director for fifteen (15) years. 

  

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 Ameriana Bank, SB 
 Supplemental Retirement Plan 
  
  


	2.2	Early Termination Benefit. If Early Termination occurs, the Bank shall distribute to the Director the benefit described in this Section 2.2 in lieu of any other benefit
under this Article. 

  

	 	2.2.1	Amount of Benefit. The benefit under this Section 2.2 is the Account Value determined as of the end of the month preceding Separation from Service.


  

	 	2.2.2	Distribution of Benefit. The Bank shall distribute the benefit to the Director in a lump sum within thirty (30) days following Separation from Service.


  

	2.3	Change in Control Benefit. If a Change in Control occurs followed within twenty-four (24) months by Separation from Service prior to Normal Retirement Age, the Bank
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 benefit under this Section 2.3 is the Account Value determined as of the end of the month preceding Separation from Service


  

	 	2.3.2	Distribution of Benefit. The Bank shall distribute the benefit to the Director in a lump sum within thirty (30) days following Separation from Service.


  

	2.4	Distributions Upon Taxation of Amounts Deferred. If, pursuant to Code Section 409A, the Federal Insurance Contributions Act or other state, local or foreign tax, the
Director becomes subject to tax on the amounts deferred hereunder, then the Bank may make a limited distribution to the Director in a manner that conforms to the requirements of Code section 409A. Any such distribution will decrease the
Director’s benefits distributable under this Agreement. 

  

	2.5	Change in Form or Timing of Distributions. For distribution of benefits under this Article 2, the Director and the Bank may, subject to the terms of Section 8.1, amend
this 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 Code Section 409A; 

  

	 	(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. 

  

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 Ameriana Bank, SB 
 Supplemental Retirement Plan 
  
  

 Article 3 
 Distribution at Death 
  

	3.1	Death During Active Service. If the Director dies prior to Separation from Service, the Bank shall distribute to the Beneficiary the benefit described in this
Section 3.1. This benefit shall be distributed in lieu of any benefit under Article 2. 

  

	 	3.1.1	Amount of Benefit. The benefit under this Section 3.1 one hundred percent (100%) of the Account Value determined as of the date of the Director’s death.


  

	 	3.1.2	Distribution of Benefit. The Bank shall distribute the benefit to the Beneficiary in a lump sum on the first day of the fourth month following the Director’s death. The
Beneficiary shall be required to provide the Director’s death certificate to the Bank. 

  

	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 Bank shall distribute to the Beneficiary the remaining benefits at the same time and in the same amounts they would have been distributed to the Director had the Director survived. 

  

	3.3	Death Before Benefit Distributions Commence. If the Director is entitled to benefit distributions under this Agreement but dies prior to the date that
commencement of said benefit distributions are scheduled to be made under this Agreement, the Bank shall distribute to the Beneficiary the same benefits to which the Director was entitled prior to death, except that the benefit distributions shall
be paid in the manner specified in Section 3.1.2 and shall commence on the first day of the fourth month following the Director’s death. 

 Article 4 
 Beneficiaries 
  

	4.1	In General. 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 Bank in which the Director participates. 

  

	4.2	 Designation. 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 the Director’s spouse as a Beneficiary, the Plan Administrator may, in its sole discretion, determine that spousal consent is required to be provided in a form
designated by the Plan Administrator, executed by the Director’s spouse and returned to the Plan Administrator. The Director’s beneficiary designation shall be deemed automatically revoked if the Beneficiary 



  

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 Ameriana Bank, SB 
 Supplemental Retirement Plan 
  
  


	 	 
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. 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, any benefit shall be paid to 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 Beneficiary, as the case may be, and shall completely discharge any liability under this Agreement for such distribution amount. 

 Article 5 
 General Limitations 
  

	5.1	Forfeiture. The Director shall forfeit any non-distributed benefits under this Agreement if during the term of this Agreement and within five (5) years following a
Separation from Service, the Director, directly or indirectly, engages in or becomes an owner, agent, officer, director or shareholder, as defined hereinafter, of any business which competes with any of the businesses conducted by the Bank, the
Holding Company or any of the subsidiaries of either in any of the following states, to-wit: Indiana, Ohio, Kentucky, Illinois and/or Michigan. The Bank and the Director agree that the term of this covenant not to compete and the geographic area
described here are reasonable given the nature of the businesses conducted by the Bank, the Holding Company and their subsidiaries and given the plans for the conduct of business made by the Bank in its strategic plans. In the event the Director
breaches this provision, the Bank may cancel all benefits provided herein upon giving the Director twenty one (21) days written notice and an opportunity to cure said breach. For purposes of this section, the Director shall be deemed a
shareholder if the Director acquires five percent (5%) or more of any publicly traded or privately held entity that competes with the Bank as aforesaid. 

  


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 Ameriana Bank, SB 
 Supplemental Retirement Plan 
  
  

 Article 6 
 Administration of Agreement 
  

	6.1	Plan Administrator Duties. 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 this Agreement to the extent the exercise of such discretion and authority does not conflict with Code Section 409A. 

  

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

  

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

  

	6.4	Indemnity of Plan Administrator. The Bank shall indemnify and hold harmless 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. 

  

	6.5	Bank Information. To enable the Plan Administrator to perform its functions, the Bank shall supply full and timely information to the Plan Administrator on all matters
relating to the date and circumstances of the Director’s death, or Separation from Service, 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. The Director or Beneficiary (“claimant”) who has not received benefits under this 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. 

  

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 Ameriana Bank, SB 
 Supplemental Retirement Plan 
  
  


	7.1.2	Timing of Plan Administrator Response. The Plan Administrator shall respond to such claimant within ninety (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 ninety (90) days by notifying the claimant in writing, prior to the end
of the initial ninety (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 this 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 this 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 sixty (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 (as defined in applicable ERISA regulations) to the
claimant’s claim for benefits. 

  

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 Ameriana Bank, SB 
 Supplemental Retirement Plan 
  
  


	 	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 sixty (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 sixty (60) days by notifying the claimant in writing, prior to
the end of the initial sixty (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. If the claim is denied then the notification shall set forth: 

  

	 	(a)	The specific reasons for the denial; 

  

	 	(b)	A reference to the specific provisions of this Agreement on which the denial is based; and 

  

	 	(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 (as
defined in applicable ERISA regulations) to the claimant’s claim for benefits. 

 Article 8 
 Amendments and Termination 
  

	8.1	Amendments. This Agreement may be amended only by a written agreement signed by the Bank and the Director. However, the Bank may unilaterally amend this Agreement to conform
with written directives to the Bank from its auditors or banking regulators or to comply with legislative changes or tax law, including without limitation Code Section 409A. 

  

	8.2	Plan Termination Generally. This Agreement may be terminated only by a written agreement signed by the Bank and the Director. The benefit shall be the Account Value as of the
date this Agreement is terminated. Except as provided in Section 8.3, the termination of this Agreement shall not cause a distribution of benefits under this Agreement. Rather, upon such termination benefit distributions will be made at the
earliest distribution event permitted under Article 2 or Article 3. 

  

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 Ameriana Bank, SB 
 Supplemental Retirement Plan 
  
  


	8.3	Plan Terminations Under Code Section 409A. Notwithstanding anything to the contrary in Section 8.2, if the Bank 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 this Agreement and further provided that all the Bank’s arrangements which are substantially similar to this 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 such termination; 

  

	 	(b)	Upon the Bank’s dissolution or with the approval of a bankruptcy court provided that the amounts deferred under this Agreement are included in the Director’s gross income
in the latest of (i) the calendar year in which this 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 

  

	 	(c)	Upon the Bank’s termination of this and all other arrangements that would be aggregated with this Agreement pursuant to Treasury Regulations Section 1.409A-1(c) if the
Director participated in such arrangements (“Similar Arrangements”), provided that (i) the termination and liquidation does not occur proximate to a downturn in the financial health of the Bank, (ii) all termination distributions
are made no earlier than twelve (12) months and no later than twenty-four (24) months following such termination, and (iii) the Bank does not adopt any new arrangement that would be a Similar Arrangement for a minimum of three
(3) years following the date the Bank takes all necessary action to irrevocably terminate and liquidate the Agreement; 

 the Bank may distribute the Account Value, determined as of the date of the termination of this 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 Bank and their beneficiaries, survivors, executors, administrators and transferees. 


 

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

  

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

  

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 Ameriana Bank, SB 
 Supplemental Retirement Plan 
  
  


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

  

	9.5	Unfunded Arrangement. The Director and the Beneficiary are general unsecured creditors of the Bank for the distribution of benefits under this Agreement. The benefits
represent the contractual obligation of the bank 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 Bank to which the Director and Beneficiary have no preferred or secured claim. 

  

	9.6	Reorganization. The Bank 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 Bank under this Agreement. Upon the occurrence of such an event, the term “Bank” as used in this Agreement shall be
deemed to refer to the successor or survivor entity. 

  

	9.7	Entire Agreement. No rights are granted to the Director by virtue of this Agreement other than those specifically set forth herein. 

  

	9.8	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. 

  

	9.9	Alternative Action. In the event it shall become impossible for the Bank or the Plan Administrator to perform any act required by this Agreement due to regulatory or other
constraints, the Bank or Plan Administrator may perform such alternative act as most nearly carries out the intent and purpose of this Agreement and is in the best interests of the Bank, provided that such alternative act does not violate Code
Section 409A. 

  

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


  

	9.11	Validity. If 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 or invalid provision had never been included herein. 

  

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 Ameriana Bank, SB 
 Supplemental Retirement Plan 
  
  


	9.12	Notice. Any notice or filing required or permitted to be given to the Bank 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: 

  

					
		  	 Ameriana Bank
	  	
		  	 2118 Bundy Avenue
	  	
		  	 New Castle, IN 47362
	  	

 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. 
  

	9.13	Deduction Limitation on Benefit Payments. If the Bank reasonably anticipates that the Bank’s deduction with respect to any distribution under this Agreement would be
limited or eliminated by application of Code Section 162(m), then to the extent deemed necessary by the Bank to ensure that the entire amount of any distribution from this Agreement is deductible, the Bank may delay payment of any amount that
would otherwise be distributed under this Agreement. The delayed amounts shall be distributed to the Director (or the Beneficiary in the event of the Director’s death) at the earliest date the Bank reasonably anticipates that the deduction of
the payment of the amount will not be limited or eliminated by application of Code Section 162(m). 

  

	9.14	Compliance with Section 409A. This Agreement shall be interpreted and administered consistent with Code Section 409A. 

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

									
	DIRECTOR	 		 	BANK
				
	 /s/ Michael E. Kent
	 		 	By:	 	 /s/ Jerome J. Gassen

	Michael E. Kent	 		 	Title:	 	 President & CEO


  

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 Ameriana Bank, SB 
 Supplemental Retirement Plan 
  
  

 { } New Designation 
 { }
Change in Designation 
 I, Michael E. Kent, designate the following as Beneficiary under this 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:	 	                      
	 	

 Received by the Plan Administrator this
                     day of
                            , 200     
  

			
	By:	 	  

		
	Title: