Spousal Consent Regarding Benefits

Spousal Consent Regarding Benefits

Employee Name: _______________________________________________________________________
Last                                            First                                         M. I.

Social Security #: ___________________________

This form must be completed by the participant's spouse unless the participant certifies that he/she is not legally married or the total benefit is less than $5,000.

CERTIFICATION FOR UNMARRIED PARTICIPANT

I certify that I am not legally married or that my total account balance is less than $5,000. I understand that a false statement by me may cause the Plan legal damages, in which event I agree to be fully responsible for all such amounts and agree that this shall be binding upon my heirs and my estate in the event of my death.

________________________________________
Signature of Unmarried Participant

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