Instructions for Plan Participants

If you certify that you are married and elect a pre-retirement death benefit other than a life annuity, your spouse’s signature is required in order to complete your designation. Please print this page and have your spouse complete and sign where indicated. Your spouse’s consent this election must be witnessed by a plan representative or a notary public. (If you certified that you are married, but cannot locate your spouse, please print this page and complete and sign where indicated. Your election must be witnessed by a plan representative or a Notary Public. Your plan representative may request evidence of this designation for their records.) Your election is not valid unless the completed consent form is returned. Return the completed consent form to:

MICHAEL INDIGO
803 TEST AVE
OSCEOLA WI 54025

If this completed consent form is not received within those 30 days, your designation(s) will be deleted.

I certify that I am:

Married

If your spouse is not named as the 100% primary beneficiary, a spousal consent form is required and must be notarized or witnessed by a plan representative. The spousal consent form is presented to you at the confirmation step of the process. Please continue.

Unmarried at this time

Because my spouse would have certain rights to my death benefit, I understand that my beneficiary designation(s) become invalid if I am married at the time of my death unless my spouse has consented, in writing, to my designations. I will immediately inform my plan representative of any change in my marital status.

Election of Pre-Retirement Death Benefit

Complete this section to elect a form of pre-retirement death benefit other than a life annuity.

Option 1 - Lump Sum.

Option 2 - Certain and Life Annuity. The period certain (select a period) is to be ___ 5 ___ 10 ___ 15 years. Monthly payments are to continue for the life of my primary beneficiary (or beneficiaries). If my primary beneficiary (or beneficiaries) should die before the end of the certain period, monthly payments are to continue to my secondary beneficiary (or beneficiaries) in the same amount for the remainder of the period.

Option 3 - Discretionary. The form of benefit shall be elected by my beneficiary (or beneficiaries) upon my death.

Spousal Consent for Participant's Election to Waive QPSA Coverage

I am the spouse of the plan participant named above and consent to the election of a pre-retirement death benefit other than a life annuity. I understand that if the plan gives me the right to revoke this consent that I may do so by delivering to the plan representative a written revocation of this consent prior to the death of my spouse. Upon the death of my spouse the consent contained herein, if not previously revoked, shall be irrevocable.

_________________________ Spouse's Printed Name	_________________________ Spouse's Signature	_________________________ Date
Only needed if participant is married, but unable to locate his or her spouse
_________________________ Participant's Printed Name	_________________________ Participant's Signature	_________________________ Date
Witnessed by:
_________________________ Plan Representative's Signature	_________________________ Date
If NOT Witnessed by a Plan Representative, Notary Public MUST Witness:
Subscribed and sworn before me this __________ day of _______________________, 20_____.
Notary Public ____________________________________________________________
County of Residence _______________________ My Commission Expires _________________________