COZEN O'CONNOR, P.C. v. TOBITS et al

Filing 14

Defendant Farley's ANSWER to 3 Amended Complaint, CROSSCLAIM against JENNIFER J. TOBITS, COUNTERCLAIM against COZEN O'CONNOR, P.C. by DAVID M. FARLEY, JOAN F. FARLEY. (Attachments: # 1 Exhibit Exhibit A, # 2 Exhibit Exhibit B, # 3 Exhibit Exhibit C, # 4 Exhibit Exhibit D)(WENGER, RANDALL)

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1

COZEN

J O'CONNOR.

Cozen O'Connor Profit Sharing Plan
Designation of Beneficiary Form
Participant
Information

•e ^ ^

- .rr-- &£oj.

Present Marital

Social Security Number

E-mail Address

(Pleaseprint cfeariy)

Name

Daytime Phono Number

D-Smgle

O Married

Status
(Check one)

Explanation of
Qualified

Preretirement

Survivor Annuity

If you are married when you die. your money purchase pension vested account balance will

be used to purchase an annuity providing periodic payments for the life of your surviving

spouse. This annuity form of payment is called a"Qualified Preretirement Survivor Annuity"
or QPSA. You may waive the QPSA. as long as your spouse consents in writing to the

waiver. In addition, after your death, your spouse may choose a form of benefit other than
the QPSA.

If you waive the QPSA. you may designate other beneficiaries and/or forms of payment for
your vested account only if your spouse consents to the specific beneficiary you designate
on this form. If you revoke your waiver ofthe QPSA. your spouse will again receive death
S?n™m ** f0ITO 0f a QPSA' unless your sP°use eltner <1> consents to a new waiver of
theQPSA, or (2) chooses another form ofbenefit after your death.

Generally, you cannot waive the QPSA until the plan year in which you turn 35. You also may
the QPSA will be automatically reinstated as of the first day of the plan year in which you turn
35. Of course, you can again waive the QPSA at that time, with proper spousal consent
After you have separated from service, you may waive the QPSA, with proper spousal
waive the QPSA. with proper consent, prior to the plan year in which you turn 35 However

consent, at any time. Such waiver will remain effective until you revoke the waiver or are
reemployed.

If you are unmarried and subsequently marry, or marry adifferent person after you sign this

form, your spouse at your death is automatically entitled to a qualified preretirement survivor
annuity and this Primary Beneficiary designation no longer applies. Thus be sure to update

this form aftera change in marital status.

This consent is required only if amarried. Participant does not name the spouse as the only
primary beneficiary. Tobeeffective, the spouse's signature must be notarized.

Beneficiary
Designation

I. the undersigned, hereby elect that upon my death the following person(s) shall be my

pnmary and secondary beneficiary(ies) under theplan:

Primary

Beneficiary(ies)

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Last----Name

/
,

First

Social Security Number

fo£/h

Stond Address

2

m.L

,

'

Woodhrcxz>k<b
. .

)

Cty

State

Birth Date

ReiatorShfr

ZIPCode

'

Percent

UstNamT

/First

Social Security Number.

StaJ&f Address

>

y.

7^

~jy* "^

e—

c»y

State

.ZIPCode

BirtfcDato

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-•Relationship

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Portent

350076 (Rev. 8/26/2009)
8/09

RBAR033S0076

Exhibit
B

Cozen O'Connor Profit Sharing Plan
Designation of Beneficiary Form

may not change beneficiaries without again getting my consent.

4. Ido nothaveto sign this consent. However, onceIdo, Icannot revoke my consent.
5. This consent has no application to the benefits that begin during my spouse's
lifetime.

6. My signature mustbe witnessed by a Notary Public for my consentto be effective.

Date

•of

Notarization of

Spouse's Signature

'Xiittr\x>;*

Spouse's Signature

1*=

Sworn to before me this

Cook-

Countyof (or Cityof)

dayof

£ifMA^le.e.

uro'efNotary Public '

Oate

Signature

Name of Notary Public

-ZOIQ

^^

My Commission Expires

Additional Beneficiaries

Additional Primary
Beneficiary(ies)

Last Name

First

ML

First

M.I.

City

State

ZIPCode

Birth Oate

Relationship

Social Security Number

Social Security Number

Street Address

Street Address

City

State

Birth Date

Relationship

ZIPCode

Percent

Additional Secondary
Beneficiary(ies)

Last Name

Percent

First

M.L

Last Name

First

M.L

City

State

ZIPCode

Birth Date

Relationship

Social Security Number

Social SecurityNumber

Street Address

Street Address

City

State

Birth Date

Relationship

ZIPCode

Percent

Percent

OFFICIAL SEAL
HEATHER A BAUER
NOTARY PUBUC -STATE OF tUJNCXS
MYCOMMSSKMEXPKE&ll/OSril

350076(Rev. 8/26/2009)

8/09
RBAR033S0076

Cozen O'Connor Profit Sharing Plan
Designation of Beneficiary Form

If you name more than one primary beneficiary but do not specify a percentage for each,

your account will be divided equally among the primary beneficiaries who survive you.
Check here ifyou have more than two primary beneficiaries and have used the space on

the next page. D
Secondary
Beneficiary(ies)

In the event the primary beneficiary(ies) is/are not living. Idesignate the following personfs)

as my beneficiary(ies):
Last Name

First

M.I.

Ml.

City

State

ZIPCode

Relationship

Social Security Number

Street Address

Birth Date

First

Birth Date

Social Security Number

City

Last Name

Street Address

State

ZIPCode

Relationship

Percent

Percent

If you name more than one secondary beneficiary but do not specify a percentage for
each your account will be divided equally among the secondary beneficiaries who
survive you. Check here ifyou have more than two secondary beneficiaries and have

used the space on the next page. •
Participant's
Signature

Any election Ihave made on this form revokes all prior^signajlons wjtrrfe5e?to this Plan.
Date

Participant's Waiver

Partkapartt'sI

^

Waiver of Preretirement Survivor Annuity

Ihave reviewed the Explanation ofthe Qualified Preretirement Survivor Annuity CQPSA")

above. Iunderstand that my preretirement death benefits will be paid in the form of aQPSA
unless Ichoose aprimary beneficiary other than my spouse and my spouse consents to the

beneficiary Iunderstand that Imay not change the beneficiary unless my spouse consents
to the new beneficiary. Ialso understand that Imay revoke my waiver ofthe QPSA at any time

bydesignating my spouse asthe sole primary beneficiary for the QPSA.

Ihereby waive the Qualified Preretirement Survivor Annuity under the plan. By signing this

warver, the individuals) that fhave designated as my primary beneficiaries Jm«I
t^I^r I f Pan,Mn!,!lS.at my death lnStead ofmV spouse. If my spouse consents to

SeQPSA
Date

Spouse's Consent

^ Ch°°Se 3f0mi °fPayment f°r death benelH8 other
Participant's Signature

Ivoluntarily consent to my spouse's election to waive the qualified preretirement survivor

annuity and to designate the beneficiaries) listed on this fori Ihave"readEE£XE

ofthe qualified preretirement survivor annuity benefit and Iunderstand that:

1. If Ido not sign this consent, the qualified preretirement survivor annuity benefit will
remain in effect.
2. By signing this consent the beneficiary(ies) designated by my spouse will receive
my spouse's plan benefits instead of me.
3. This consent applies only to the beneficiaries designated on this form. My spouse
350076 (Rev. 8/26/2009)
8/09