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Back to Forms for 'Wills'.





Date: ______________________


To: _______________________



BE IT ACKNOWLEDGED, that ________________________________________ of ___________________________________________________________________, is

hereby 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 made. 

Please forward any necessary change of beneficiary forms.



Signed under seal this ________________ day of ____________ (month), ____ (year).



_________________________________ Insured




STATE OF _______________________   COUNTY OF _______________________


On ___________________ 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.


WITNESS my hand and official seal.






Affiance       ____ Known         ____ Unknown


ID Produced: _________________________






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