DESIGNATION OF BENEFICIARY INFORMATION
(Read Privacy Act Statement and Instructions on back before completing this form.)
(After completing this form, make a copy for your records.)
1.a. RETIRED MEMBER'S NAME (Last, first, middle initial)
b. SSN
2. DESIGNATED BENEFICIARY INFORMATION
(2) FULL NAME (Last, first, middle initial)
(3) SSN
(4) RELATIONSHIP
a.
(1) SHARE
(5) ADDRESS (Street, Apartment Number, City, State and ZIP Code)
%
(2) FULL NAME (Last, first, middle initial)
(3) SSN
(4) RELATIONSHIP
b.
(1) SHARE
(5) ADDRESS (Street, Apartment Number, City, State and ZIP Code)
%
(2) FULL NAME (Last, first, middle initial)
(3) SSN
(4) RELATIONSHIP
c.
(1) SHARE
(5) ADDRESS (Street, Apartment Number, City, State and ZIP Code)
%
(2) FULL NAME (Last, first, middle initial)
(3) SSN
(4) RELATIONSHIP
d.
(1) SHARE
(5) ADDRESS (Street, Apartment Number, City, State and ZIP Code)
%
(2) FULL NAME (Last, first, middle initial)
(3) SSN
(4) RELATIONSHIP
e.
(1) SHARE
(5) ADDRESS (Street, Apartment Number, City, State and ZIP Code)
%
3. IF YOU DO NOT ELECT TO DESIGNATE BENEFICIARIES ABOVE, PLEASE PROVIDE THE INFORMATION REQUESTED BELOW FOR
FAMILY MEMBERS WHO MAY BE CONTACTED IN THE EVENT OF YOUR DEATH.
(1) FULL NAME (Last, first, middle initial)
(2) SSN
(3) RELATIONSHIP
a.
(4) ADDRESS (Street, Apartment Number, City, State and ZIP Code)
(1) FULL NAME (Last, first, middle initial)
(2) SSN
(3) RELATIONSHIP
b.
(4) ADDRESS (Street, Apartment Number, City, State and ZIP Code)
(1) FULL NAME (Last, first, middle initial)
(2) SSN
(3) RELATIONSHIP
c.
(4) ADDRESS (Street, Apartment Number, City, State and ZIP Code)
(1) FULL NAME (Last, first, middle initial)
(2) SSN
(3) RELATIONSHIP
d.
(4) ADDRESS (Street, Apartment Number, City, State and ZIP Code)
(1) FULL NAME (Last, first, middle initial)
(2) SSN
(3) RELATIONSHIP
e.
(4) ADDRESS (Street, Apartment Number, City, State and ZIP Code)
4.a. RETIRED MEMBER SIGNATURE
b. DATE SIGNED
DD FORM 2894, APR 2017
PREVIOUS EDITION IS OBSOLETE.
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