WebSocial Security/Tax ID Number Date of Birth/Trust Date (mm/dd/yyyy) Mailing Address . City State or Province. Zip or Postal Code Telephone Number Email Address. Country(ies) of Citizenship (Must list each separated by a comma.) USA. Other: Country of Legal Residence (Select only one.) USA Other: WebdATE Of BiRTh/TRuST dATE (MM/dd/yyyy) PERCENTAgE (MuST TOTAl 100% fOR All PRiMARy RECiPiENTS) ( ) recipient designation form • rev 5/10 • page 2 of 4. Recipient Designation Form continued Check box if additional recipients are listed on an attachment. Identify each as primary or secondary.
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