(1) The following statutory form shall be the standard form for a designated beneficiary agreement: DESIGNATED BENEFICIARY AGREEMENT ______________________________________________________________ DISCLAIMER Warning: While this document may indicate your wishes, certain additional documents may be needed to protect these rights. This designated beneficiary agreement is operative in the absence of other estate planning documents and will be superseded and set aside to the extent it conflicts with valid instruments such as a will, power of attorney, or beneficiary designation on an insurance policy or pension plan. This designated beneficiary agreement is superseded by such other documents and does not cause any changes to be made to those documents or designations. The parties understand that executing and signing this agreement is not sufficient to designate the other party for purposes of any insurance policy, pension plan, payable upon death designation or manner in which title to property is held and that additional action will be required to make or change such designations. The parties understand that this designated beneficiary agreement may be one component of estate planning instructions and that they are encouraged to consult an attorney to ensure their estate planning wishes are accomplished. ______________________________________________________________ We, _______________, (insert full name and address) referred to as party A, and _______________, (insert full name and address) referred to as party B, hereby designate each other as the other's designated beneficiary with the following rights and protections, granted or withheld as indicated by our initials: TO GRANT ONE OR MORE OF THE RIGHTS OR PROTECTIONS SPECIFIED IN THIS FORM, INITIAL THE LINE TO THE LEFT OF EACH RIGHT OR PROTECTION YOU ARE GRANTING. TO WITHHOLD A RIGHT OR PROTECTION, INITIAL THE LINE TO THE RIGHT OF EACH RIGHT OR PROTECTION YOU ARE WITHHOLDING. A DESIGNATED BENEFICIARY AGREEMENT SHALL BE PRESUMED TO GRANT ALL OF THE RIGHTS AND PROTECTIONS LISTED IN THIS FORM UNLESS THE PARTIES WITHHOLD A RIGHT OR PROTECTION IN THE MANNER SET FORTH IMMEDIATELY ABOVE. TO GRANT A RIGHT TO WITHHOLD A RIGHT OR PROTECTION OR PROTECTION INITIAL INITIAL Party A Party B Party A Party B ___ ___ The right to acquire, hold title to, own___ ___ jointly, or transfer inter vivos or at death real or personal property as a joint tenant with me with right of survivorship or as a tenant in common with me; ___ ___ The right to be designated by me as a ___ ___ beneficiary, payee, or owner as a trustee named in an inter vivos or testamentary trust for the purposes of a nonprobate transfer on death; ___ ___ The right to be designated by me as a ___ ___ beneficiary and recognized as a dependent in an insurance policy for life insurance; ___ ___ The right to be designated by me as a ___ ___ beneficiary and recognized as a dependent in a health insurance policy if my employer elects to provide health insurance coverage for designated beneficiaries; ___ ___ The right to be designated by me as a ___ ___ beneficiary in a retirement or pension plan; ___ ___ The right to petition for and have ___ ___ priority for appointment as a conservator, guardian, or personal representative for me; ___ ___ The right to visit me in a hospital, ___ ___ nursing home, hospice, or similar health care facility in which a party to a designated beneficiary agreement resides or is receiving care; ___ ___ The right to initiate a formal ___ ___ complaint regarding alleged violations of my rights as a nursing home patient as provided in section 25-1-120, Colorado Revised Statutes; ___ ___ The right to act as a proxy ___ ___ decision-maker or surrogate decision- maker to make medical care decisions for me pursuant to section 15-18.5-103 or 15- 18.5-104, Colorado Revised Statutes; ___ ___ The right to notice of the withholding ___ ___ or withdrawal of life-sustaining procedures for me pursuant to section 15-18-107, Colorado Revised Statutes; ___ ___ The right to challenge the validity of ___ ___ a declaration as to medical or surgical treatment of me pursuant to section 15-18-108, Colorado Revised Statutes; ___ ___ The right to act as my agent to make, ___ ___ revoke, or object to anatomical gifts involving my person pursuant to the "Revised Uniform Anatomical Gift Act", part 2 of article 19 of title 15, Colorado Revised Statutes; ___ ___ The right to inherit real or personal ___ ___ property from me through intestate succession; ___ ___ The right to have standing to receive ___ ___ benefits pursuant to the "Workers' Compensation Act of Colorado", article 40 of title 8, Colorado Revised Statutes, in the event of my death on the job; ___ ___ The right to have standing to sue for ___ ___ wrongful death in the event of my death; and ___ ___ The right to direct the disposition of ___ ___ my last remains pursuant to article 19 of title 15, Colorado Revised Statutes. THIS DESIGNATED BENEFICIARY AGREEMENT IS EFFECTIVE WHEN RECEIVED FOR RECORDING BY THE COUNTY CLERK AND RECORDER OF THE COUNTY IN WHICH ONE OF THE DESIGNATED BENEFICIARIES RESIDES. THIS DESIGNATED BENEFICIARY AGREEMENT WILL CONTINUE IN EFFECT UNTIL ONE OF THE DESIGNATED BENEFICIARIES REVOKES THIS AGREEMENT BY RECORDING A REVOCATION OF DESIGNATED BENEFICIARY FORM WITH THE COUNTY CLERK AND RECORDER OF THE COUNTY IN WHICH THIS AGREEMENT WAS RECORDED OR UNTIL THIS AGREEMENT IS SUPERSEDED IN PART OR IN WHOLE BY A SUPERSEDING LEGAL DOCUMENT. ___________________________ _____________________________ Signature of designated beneficiary Signature of designated beneficiary STATE OF COLORADO County of ______________ This document was acknowledged before me on ___________date by ________________________ My commission expires ______________ [Seal] _______________________________ Notary Public (2) The instructions to each party regarding how to grant or withhold a right or protection by initialing and the words "Party A" and "Party B" shall appear at the top of each page of the statutory form above the columns for the initials of the designated beneficiaries. (3) A designated beneficiary agreement shall be presumed to extend all of the rights and protections listed in the statutory form unless the parties to the agreement explicitly exclude a right or protection. (4) A party to a designated beneficiary agreement may limit the scope of a designated beneficiary agreement by the terms of the agreement or by executing a superseding legal document that controls and supersedes part or all of the designated beneficiary agreement.
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