1. Member Information

^{Member Name (first, middle initial, last)}

^Address

^{Social Security Number}

^City

^State

^{ZIP Code}

^{Email Address}

^{Home Phone}

2. Designation of Beneficiary(ies)

The following individual(s) shall be my beneficiary(ies). Please check Primary or Contingent for each individual beneficiary. If neither is checked, the individual will be deemed to be a primary beneficiary. If any primary or contingent beneficiary dies before me, his or her interest and the interest of his or her heirs shall terminate completely, and the percentage share of any remaining beneficiary(ies) shall be increased on a pro rata basis. If no primary beneficiary(ies) survives me, the contingent beneficiary(ies) shall acquire the designated share of my plan balance.

(When added up, the total share percentages of all primary beneficiaries must equal 100%)

ð Primary   ð Contingent

^{% Share}

^Name

^Address

^{Date of Birth}

^Relationship

^City

^State

^{ZIP Code}

^{Social Security Number}

ð Primary   ð Contingent

^{% Share}

^Name

^Address

^{Date of Birth}

^Relationship

^City

^State

^{ZIP Code}

^{Social Security Number}

ð Primary   ð Contingent

^{% Share}

^Name

^Address

^{Date of Birth}

^Relationship

^City

^State

^{ZIP Code}

^{Social Security Number}

ð Primary   ð Contingent

^{% Share}

^Name

^Address

^{Date of Birth}

^Relationship

^City

^State

^{ZIP Code}

^{Social Security Number}

3. Signatures

I consent to the beneficiary(ies) designated in section 2 and revoke all prior designations. I understand that I may change my beneficiary(ies) by completing a Lao Investment Club Designation of Beneficiary Form and sending it to the Lao Investment Club.

Spousal Consent
If your residence is in a community or marital property state and you name a nonspouse as beneficiary, your spouse must consent by signing below.

I am the spouse of the above-named account holder. I acknowledge that I have received a fair and reasonable disclosure of my spouse’s property and financial obligations. Due to the important tax consequences of giving up my interest in this account, I have been advised to see a tax professional. I hereby give the account holder any interest I have in the funds or properties deposited in this account and consent to the beneficiary designation indicated above. I assume full responsibility for any adverse consequences that may result. No tax or legal advice was given to me by the Lao Investment Club.

4. Return Information

Please mail completed form to:
Lao Investment Club
Attn: Member Relations Office
45374 Zuma Dr.
Temecula, CA 92592

If you have any questions regarding the completion of this form, please e-mail the Member Support Center at laoinvestmentclub@etrademail.com

Copyright © 2000 Lao Investment Club. All rights reserved.

DOB