Designation Of Beneficiary Form - Tennessee Board Of Regents
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1TENNESSEE BOARD OF REGENTS
MIDDLE TENNESSEE STATE UNIVERSITY
DESIGNATION OF BENEFICIARY
EMPLOYEE NAME: ______________________________________________________________________
(Last)
(First)
(Maiden)
(Middle)
EMPLOYEE "M" NO.: ________________________
In accordance with the Tennessee Board of
ensation of wages and benefits in the
Regents procedure to disburse final comp
event of employee death; I hereby designate the beneficiary (ies) listed below:
Complete either Sections I and III or Sections II and III
SECTION I
SAME BENEFICIARY AS DESIGNATED FOR RETIREMENT
I designate payment of all wages and benefits to the same beneficiary (ies) designated for retirement benefits.
Yes
No (If you enter "Yes", go to the Employee Signature line in Section III.)
SECTION II (Social Security number is required for federal reporting.)
WAGES (TCA §30-2-103)
____________________________________________________________________________________________________
(Last Name)
(First Name)
(Middle)
(Soc. Sec. No.)
(Birthdate)
(Sex) (Relationship)
ANNUAL LEAVE (TCA §8-50-808 and TBR POLICY 5:01:01:01, Section III.E.)
____________________________________________________________________________________________________
(Last Name)
(First Name)
(Middle)
(Soc. Sec. No.)
(Birthdate)
(Sex) (Relationship)
SICK LEAVE (TCA §8-50-808 and TBR POLICY 5:01:01:01, Section VII)
____________________________________________________________________________________________________
(Last Name)
(First Name)
(Middle)
(Soc. Sec. No.)
(Birthdate)
(Sex) (Relationship)
COMPENSATORY TIME (TCA §8-50-808)
____________________________________________________________________________________________________
(Last Name)
(First Name)
(Middle)
(Soc. Sec. No.)
(Birthdate)
(Sex) (Relationship)
ESTATE
___________________________________
ADDRESS: ___________________________________
SECTION III
I, the employee, revoke any previous beneficiary nominations and direct that the foregoing designations supersede any
previously filed.
EMPLOYEE SIGNATURE ________________________________________ DATE _____________________________
STATE OF TENNESSEE
COUNTY OF RUTHERFORD
________________________________________________ personally appeared before me on this the ____________ day of
_________________________, _____________, who makes oath that he/she executed the foregoing instrument.
(NOTARY SEAL)
Notary Public: _________________________________________
My Commission Expires: ________________________________
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