Designation Of Beneficiary For Community Property - Lacers Page 2
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2DESIGNATION OF BENEFICIARY FOR COMMUNITY PROPERTY
Additional Primary Beneficiaries (Complete this section only if you want to name more primary
beneficiaries than you had room to list on the front of this form):
_____________________________________________________ __________________________
Name
Date of Birth
___________________________ ____________________________ _______________________
Relationship
Social Security Number (Optional)
Telephone Number
___________________________ ____________________________ ________ _____________
Street Address (No PO Boxes)
City
State
Zip Code
_____________________________________________________ __________________________
Name
Date of Birth
___________________________ ____________________________ _______________________
Relationship
Social Security Number (Optional)
Telephone Number
___________________________ ____________________________ ________ _____________
Street Address (No PO Boxes)
City
State
Zip Code
Additional Secondary Beneficiaries (Complete this section only if you want to name more
secondary beneficiaries than you had room to list on the front of this form):
_____________________________________________________ __________________________
Name
Date of Birth
___________________________ ____________________________ _______________________
Relationship
Social Security Number (Optional)
Telephone Number
___________________________ ____________________________ ________ _____________
Street Address (No PO Boxes)
City
State
Zip Code
_____________________________________________________ __________________________
Name
Date of Birth
___________________________ ____________________________ _______________________
Relationship
Social Security Number (Optional)
Telephone Number
___________________________ ____________________________ ________ _____________
Street Address (No PO Boxes)
City
State
Zip Code
_________________________________________________ ______________________________
Applicant’s Signature
Date
Revised June 2013
2 of 2
12/05/2014
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