EX-10.66



 Exhibit 10.66 
 PLUMAS BANK 
 DIRECTOR RETIREMENT AGREEMENT 

THIS DIRECTOR RETIREMENT AGREEMENT (the “Agreement”) is adopted this 21st day of September, 2011, by and
between PLUMAS BANK, a California corporation located in Quincy, California (the “Company”) and Robert McClintock (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 Accounting Principles Board Opinion Number 12 (“APB 12”) as amended by Statement of Financial Accounting Standards Number 106
(“FAS 106”) 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. 










	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 six
percent (6%). 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 August 1, 2011. 



 

	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 August 1st and ending on July 31st of each year. The initial
Plan Year shall commence on the Effective Date of this Agreement and end on the following July 31, 2012. 


  

	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: 



 

				September 30,	
	 Year ending
	    	Monthly Benefit	 
	 8/31/12
	    	$	101.63	  
	 8/31/13
	    	$	189.76	  
	 8/31/14
	    	$	272.78	  
	 8/31/15
	    	$	350.97	  
	 8/31/16
	    	$	424.62	  
	 8/31/17
	    	$	494.00	  
	 8/31/18
	    	$	559.34	  
	 8/31/19
	    	$	620.88	  
	 8/31/20
	    	$	678.85	  
	 8/31/21
	    	$	733.46	  
	 8/31/22
	    	$	784.89	  
	 8/31/23
	    	$	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. 


  

	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. 


  

	 	2.3.1Amount	 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. 










	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. 










	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 










	 	(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. 








	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/ Robert McClintock
	 		 	By	 	 /s/ Andrew Ryback

	Robert McClintock	 		 		 	Title President and CEO








 PLUMAS BANK 
 Director Retirement Agreement 
 BENEFICIARY DESIGNATION FORM 

{ } New Designation 
 { } Change in Designation

 I, Robert McClintock, designate the following as Beneficiary under the Agreement: 

 

				September 30,	
	 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: _________________________________