Designation For Outstanding Wage Payments Form - Georgia Department Of Human Services
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1
2GEORGIA DEPARTMENT OF HUMAN SERVICES
DESIGNATION FOR OUTSTANDING WAGE PAYMENTS
IMPORTANT!! Please Read Instructions on Reverse Side Before Completing This Form.
1 -
EMPLOYEE'S DESIGNATION OF BENEFICIARY (To Receive Any Outstanding
Wages
Or
Other
Moneys
Upon
the
Employee's
Death)
*
In the event that upon my death I have wages or other moneys due me from the State of Georgia, Department of
Human Services, by this statement I authorize all such sums to be paid to the following individual whom I hereby
designate as my beneficiary of any such sums:
Employee's Signature ___________________________________________
SSN _____________________
Employee's Name ______________________________________________
Date _____________________
(please print)
Please provide the following information:
A. BENEFICIARY
Beneficiary's Name _____________________________________________
SSN _____________________
Address ______________________________________________________
Phone # __________________
NOTE: Where the above beneficiary is under a legal incapacity to receive such sums, please indicate, if known, the
name and address of the duly qualified guardian of the beneficiary.
B.
DULY
QUALIFIED
GUARDIAN
Guardian's Name _______________________________________________
SSN _____________________
Address ______________________________________________________
Phone # __________________
2 -
SURVIVING SPOUSE OR SURVIVING MINOR CHILDREN (To Receive Any
Outstanding
Wages
Or
Other
Moneys
Upon
the
Employee's
Death)
*
In the event that upon my death I have wages or other moneys due me from the State of Georgia, Department of
Human Services, and in the absence of a designated beneficiary, by this statement, I authorize all such sums to
be paid to my surviving spouse and in the absence of a surviving spouse, I authorize all such sums to be paid to the
duly qualified guardian of my surviving minor child or children:
Employee's Signature ___________________________________________
SSN _____________________
Employee's Name ______________________________________________
Date _____________________
Please provide the following information:
A. SPOUSE
Spouse's Name ________________________________________________
SSN _____________________
Address ______________________________________________________
Phone # __________________
B.
MINOR
CHILD
OR
CHILDREN
Child's/Children's Name(s) ________________________________________ SSN _____________________
Address ______________________________________________________
Phone # __________________
NOTE: Please indicate, if known, the name and address of the duly qualified guardian.
C. DULY QUALIFIED GUARDIAN
Guardian's Name(s) ____________________________________________
SSN _____________________
Address ______________________________________________________
Phone # __________________
º
NOTE: It is the responsibility of the employee to furnish and to keep this information current!!
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