OF BENEFICIARY NOTICE
IT ACKNOWLEDGED, that ________________________________________ of
designated beneficiary in and to a certain life insurance policy numbered _____
_______________ and issued by __________________________. Said policy is dated ____________________
(date). The present death benefit
payable is in the amount of $____________________ on the life of the
undersigned. This change of beneficiary
acknowledgment terminates all prior designations of beneficiary heretofore
forward any necessary change of beneficiary forms.
under seal this ________________ day of ____________ (month), ____ (year).
STATE OF _______________________ COUNTY OF _______________________
___________________ before me, ________________________, personally appeared,
personally known to me (or proved to me on the basis of satisfactory evidence)
to be the person(s) whose name(s) is/are subscribed to the within instrument
and acknowledged to me that he/she/they executed the same in his/her/their
authorized capacity(ies), and that by his/her/their signature(s) on the
instrument the person(s), or the entity upon behalf of which the person(s)
acted, executed the instrument.
my hand and official seal.
Affiance ____ Known ____ Unknown
ID Produced: _________________________