Payable-on-Death Beneficiary Designation Form

Designates payable-on-death (POD) beneficiaries for a deposit account and captures the minimum identifying information needed to process the designation.

Account Holder Information

• Account Holder Full Name
• Deposit Account Number (Last 4 Digits)
  Enter only the last 4 digits to support data minimization.
• Account Type
• Contact Email
  Optional. Used only if the institution needs to follow up about this designation.

Designation Details

• What would you like to do?
• Effective Date
  The date you want this designation request to take effect.
• Is this a joint account?
• Joint Owner Consent
  Confirm that all required joint owners have consented to this designation, if applicable.

Primary Beneficiaries

• Primary Beneficiaries

Beneficiary Details

• Beneficiary Full Name
• Relationship to Account Holder
• Allocation Percentage
  Enter a whole number percentage. All primary beneficiaries should total 100%.
• Beneficiary Date of Birth
  Optional unless needed to distinguish between beneficiaries with similar names.
• Beneficiary Mailing Address
  Optional. Collect only if required by your institution's policy or for identity verification.

Contingent Beneficiaries

• Would you like to add contingent beneficiaries?
• Contingent Beneficiaries

Consent, Disclosure, and Certification

• I acknowledge that POD designations may be governed by account agreement terms and applicable law.
• I consent to the collection and use of the personal information provided in this form for beneficiary designation processing.
• Certification
  Sign to certify that the information provided is accurate and that you are authorized to make this request.
• Additional Notes
  Optional. Use this field only for information relevant to processing this designation.