Form 8a Alabama Peace Officers Annuity & Benefit
Download a blank fillable Form 8a Alabama Peace Officers Annuity & Benefit in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 8a Alabama Peace Officers Annuity & Benefit with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1FORM 8-A
ALABAMA PEACE OFFICERS' ANNUITY & BENEFIT FUND
514 South McDonough Street, Post Office Box 2186
Montgomery, Alabama 36102-2186
APPLICATION FOR DEATH BENEFITS
TO: THE BOARD OF COMMISSIONERS
Date of Signature_________________________
In accordance with the provisions of Section 12, Death Benefits, Act No. 999, as amended, I hereby,
as Beneficiary of the Deceased, make application for Death Benefits.
PART I
1. Name of Deceased Member_____________________________________________________
2. Date of death of Deceased Member_______________________________________________
3. Name of last employer of Deceased Member________________________________________
4. Give cause of death of Deceased Member__________________________________________
a. Natural Causes_____________________________________________________________
b. Killed in Line of Duty_________________________________________________________
(If answer is YES, explain in detail the circumstances)
____________________________________________________________________________
5. Signature of Beneficiary_________________________________________________________
6. Social Security No. of Beneficiary__________________________________________________
(Death benefits are reported to the Internal Revenue Service)
7. Relationship of Beneficiary to Deceased____________________________________________
8. Current Address of Beneficiary____________________________________________________
____________________________________________________________________________
9. Telephone Number_____________________ Membership No. of Deceased________________
10. Social Security No. of Deceased__________________________________________________
_______________________________________________________________________________
State of Alabama, County of____________________________
On this __________ day of _____________________________, _______, personally appeared
before me, the above named_______________________________________________________
and made oath that the statements made above are true.
Signature of Notary Public_____________________________
_______________________________________________________________________________
PART II - TO BE FILLED IN BY LAST EMPLOYER
1. Date Deceased Member's services as a peace officer ceased____________________________
2. Indicate if death was from natural causes or occurred in line of duty_______________________
_____________________________________________________________________________
3. Signature of Employer___________________________________________________________
(Title)
(Date)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal