Designation of Beneficiary
Unpaid Compensation of Deceased Civilian Employee
Important:
Read all instructions on reverse side
before filling in this form
A Identification
Employee Name (
)
Date of Birth (
)
Social Security Number
Last, First Middle
mm, dd, yyyy
Department of agency in which presently employed or former department or agency):
Department or Agency
Bureau
Division
Location (City, State and Zip code)
NAF Employment
CHERRY POINT NC 28533-0009
I, the employee named above, canceling any and all previous Designations of Beneficiary heretofore made by me, do now designate the
beneficiary or beneficiaries named below to receive any unpaid compensation due as defined in 5 U.S.C. 5581, 5582, 5583, and in no way
will affect the disposition of any benefit which may become payable under the Retirement or Group Life Insurance Acts applicable to my
Government service. I further understand that this Designation of Beneficiary will remain in full force and effect until (1) expressly change or
revoke it in writing, (2) I transfer to another agency, or (3) I am reemployed by the same or another department or agency of the Government.
B. Information concerning the Beneficiaries (See Examples of Designations)
First name, middle initial,
Address (Including Zip
Share to be
and last name of each
code) of each beneficiary
Relationship
paid to each
Date of Birth
Social Security
beneficiary
beneficiary
Number
Your Signature:
Total = 100 %
Date of designation (mm, dd, yyyy)
C. Witnesses (A witness is not eligible to receive payment as a beneficiary)
Signature of witness
Number and street
City, State and Zip code
Signature of witness
Number and street
City, State and Zip code
Receiving agency certification
I have received this designation and certify that the designated shares total 100% and that no witnesses are designated as
beneficiaries.
Date Received__________
Signature _______________________________
Type or print your return address to insure return
U.S. Office of Personnel Management
Standard Form 1152
5 CFR 178
1
