Form 140 Dividend Option Change Catholic Order Of Foresters Page 3

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BRINGING CATHOLIC VALUES TO LIFE!
DIVIDEND OPTION CHANGE/
WITHDRAWAL REQUEST FORM
A Catholic Fraternal Benefit Life Insurance Society Since 1883
POLICY #
INSURED NAME (First, MI, Last)
DATE OF BIRTH
ALL OWNERS, APPLICABLE IRREVOCABLE BENEFICIARY(IES) OR COLLATERAL ASSIGNEE(S) MUST SIGN THIS FORM.
SECTION 4: OWNER SIGNATURE
When signing as Power of Attorney on behalf of the Owner, please include your title and the complete paperwork indicating legal powers to conduct
life insurance transactions for the named Owner (if not already on file at the Home Office).
OWNER SIGNATURE
TITLE (If acting as a Representative or Authorized Officer)
DATE
OWNER SIGNATURE
TITLE (If acting as a Representative)
DATE
Notary Stamp and signature
☐ Please have this document notarized.
PUBLIC NOTARY ENDORSEMENT
On the ______ day of ___________________ 20___, came before
me the individual(s) whose signature(s) appear above.
My commission expires
FOR AGENT USE
AGENT SIGNATURE
DATE
AGENT NUMBER
Page 3 of 4
Form 140 (5/15) 15-05-039A

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