Colo. Rev. Stat. § 15-22-106
DESIGNATED BENEFICIARY AGREEMENT
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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This designated beneficiary agreement is operative in the absence of other estate planning documents and will be superseded and set aside to the extent it conflicts with valid instruments such as a will, power of attorney, or beneficiary designation on an insurance policy or pension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 This designated beneficiary agreement is superseded by such other documents and does not cause any changes to be made to those documents or designations.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.
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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
TO GRANT A RIGHT OR PROTECTION INITIAL | TO WITHHOLD A RIGHT OR PROTECTION 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
C.R.S. § 15-22-106
For provisions relating to the time of taking effect or the provisions for transition of this code, see § 15-17-101 .