CHANGE
OF BENEFICIARY NOTICE
Date:
______________________
To:
_______________________
BE
IT ACKNOWLEDGED, that ________________________________________ of
___________________________________________________________________, is
hereby
designated beneficiary in and to a certain life insurance policy numbered _____
_______________ and issued by __________________________. Said policy is dated ____________________
(date). The present death benefit
payable is in the amount of $____________________ on the life of the
undersigned. This change of beneficiary
acknowledgment terminates all prior designations of beneficiary heretofore
made.
Please
forward any necessary change of beneficiary forms.
Signed
under seal this ________________ day of ____________ (month), ____ (year).
_________________________________
Insured
______________________________________________________________________
Address
STATE OF _______________________ COUNTY OF _______________________
On
___________________ before me, ________________________, personally appeared,
personally known to me (or proved to me on the basis of satisfactory evidence)
to be the person(s) whose name(s) is/are subscribed to the within instrument
and acknowledged to me that he/she/they executed the same in his/her/their
authorized capacity(ies), and that by his/her/their signature(s) on the
instrument the person(s), or the entity upon behalf of which the person(s)
acted, executed the instrument.
WITNESS
my hand and official seal.
____________________________________
Signature
Affiance ____ Known ____ Unknown
ID Produced: _________________________
(Seal)
