Designation of Beneficiary Important: Read all instructions before filling in this form Unpaid Compensation of Deceased Civilian Employee A. Identification Name (Last, first, middle) Date of birth (mm, dd, yyyy) Social Security Number Department or agency in which presently employed (or former department or agency) : Department or agency Bureau Location (City, state and ZIP code) Division I, the employee named above, canceling any and all previous Designations of Beneficiary heretofore made by me, do now designate the beneficiary or beneficiaries named below to receive any unpaid compensation due and payable after my death. I understand that this Designation of Beneficiary relates solely to money due as defined in 5 U.S.C. 5581, 5582, 5583, and in no way will affect the disposition of any benefit which may become payable under the Retirement or Group Life Insurance Acts applicable to my Government service. I further understand that this Designation of Beneficiary will remain in full force and effect until (1) I expressly change or revoke it in writing, (2) I transfer to another agency, or (3) I am reemployed by the same or another department or agency of the Government. B. Information Concerning The Beneficiaries (See Examples of Designations): First name, middle initial, and last name of each beneficiary Date of designation (mm, dd, yyyy) Address (Including ZIP code) of each beneficiary Relationship Share to be paid to each beneficiary Your signature Total = % C. Witnesses (A witness is not eligible to receive payment as a beneficiary): We, the undersigned, certify that this statement was signed in our presence. Signature of witness Number and street City, state and ZIP code Signature of witness Number and street City, state and ZIP code Receiving agency certification I have reviewed this designation and certify that the designated shares total 100% and that no witnesses are designated as beneficiaries. Date received Signature Date Type or print your return address to insure return U.S. Office of Personnel Management 5 CFR 178 NSN 7540-00-634-4340 Part 1 - Original 1152- November 1991 edition usable until September 2002. All previous editions are not usable. Standard Form 1152 Revised June 2002 American LegalNet, Inc. www.FormsWorkFlow.com Important - The filing of this form will completely cancel any Designation of Beneficiary you may have previously filed. Be sure to name in this form all persons you wish to designate as beneficiaries of any unpaid compensation payable at your death. Examples of Designations 1. HOW TO DESIGNATE ONE BENEFICIARY First name, middle initial, and last name of each beneficiary Mary E. Brown Address (Including ZIP code) of each beneficiary 214 Central Avenue Muncie, IN 47303 2. HOW TO DESIGNATE MORE THAN ONE First name, middle initial, and last name of each beneficiary Do not write names as M.E. Brown or as Mrs. John H. Brown. If you want to designate your estate as beneficiary, enter “My estate” in the beneficiary column. Relationship Share to be paid to each beneficiary Niece 100% Be sure that the shares to be paid to the several beneficiaries add up to 100 percent. Address (Including ZIP code) of each beneficiary Relationship Share to be paid to each beneficiary Alice M. Long 509 Canal Street Red Bank, NJ 07701 Aunt 25% Joseph P. Brady 360 Williams Street Red Bank, NJ 07701 Nephew 25% Catherine L. Rowe 792 Broadway Whiting, IN 46394 Mother 50% Relationship Share to be paid to each beneficiary 3. HOW TO DESIGNATE A CONTINGENT BENEFICIARY First name, middle initial, and last name of each beneficiary Address (Including ZIP code) of each beneficiary John M. Parrish, if living 810 West 180th Street New York, NY 10033 Father 100% Otherwise to: Susan A. Parrish 810 West 180th Street New York, NY 10033 Sister 100% 4. HOW TO CANCEL A DESIGNATION OF BENEFICIARY AND EFFECT PAYMENT UNDER ORDER OF PRECEDENCE (See back of duplicate) First name, middle initial, and last name of each beneficiary Address (Including ZIP code) of each beneficiary Relationship Share to be paid to each beneficiary Cancel prior designations U.S. Office of Personnel Management 5 CFR 178 Standard Form 1152 (Reverse of Part 1) Revised June 2002 American LegalNet, Inc. www.FormsWorkFlow.com Designation of Beneficiary Important: Read all instructions before filling in this form Unpaid Compensation of Deceased Civilian Employee A. Identification Name (Last, first, middle) Date of birth (mm, dd, yyyy) Social Security Number Department or agency in which presently employed (or former department or agency) : Department or agency Bureau Location (City, state and ZIP code) Division I, the employee named above, canceling any and all previous Designations of Beneficiary heretofore made by me, do now designate the beneficiary or beneficiaries named below to receive any unpaid compensation due and payable after my death. I understand that this Designation of Beneficiary relates solely to money due as defined in 5 U.S.C. 5581, 5582, 5583, and in no way will affect the disposition of any benefit which may become payable under the Retirement or Group Life Insurance Acts applicable to my Government service. I further understand that this Designation of Beneficiary will remain in full force and effect until (1) I expressly change or revoke it in writing, (2) I transfer to another agency, or (3) I am reemployed by the same or another department or agency of the Government. B. Information Concerning The Beneficiaries (See Examples of Designations): First name, middle initial, and last name of each beneficiary Date of designation (mm, dd, yyyy) Address (Including ZIP code) of each beneficiary Relationship Share to be paid to each beneficiary Your signature Total = % C. Witnesses (A witness is not eligible to receive payment as a beneficiary): We, the undersigned, certify that this statement was signed in our presence. Signature of witness Number and street City, state and ZIP code Signature of witness Number and street City, state and ZIP code Receiving agency certification I have reviewed this designation and certify that the designated shares total 100% and that no witnesses are designated as beneficiaries. Date received Signature Date Type or print your return address to insure return U.S. Office of Personnel Management 5 CFR 178 NSN 7540-00-634-4340 Part 2 - Employee Copy 1152- November 1991 edition usable until September 2002. All previous editions are not usable. Standard Form 1152 Revised June 2002 American LegalNet, Inc. www.FormsWorkFlow.com IMPORTANT NOTICE – ORDER OF PRECEDENCE If there is no designated beneficiary alive at the time of your death, any unpaid compensation owed you (that becomes payable after you die) will be paid to the first person or persons in the order listed below who are alive on the date that entitlement to the payment occurs. 1. To your widow or widower. 2. If neither of the above, to your child or children in equal shares. The share of any deceased child is distributed to the descendants of that child. 3. If none of the above, to your parents in equal shares or the entire amount to the surviving parent. 4. If none of the above, to the duly appointed legal representative of your estate. If there is none, to the person or persons entitled under the laws of the State or other domicile where you lived. You do not need to designate a beneficiary unless you want to name some person or persons not listed above or you want the payment to be made in a different order. INSTRUCTIONS 1. The examples on the back of the first page of this form may be helpful to you in filling out this form. 2. Except for signatures, you should type or print all entries in ink (typing is preferred). You should use this form for any designation of beneficiary or beneficiaries. The form must be signed and witnessed. 3. The form should be free of erasures or alterations to avoid a possible legal contest after your death. 4. You do not need to fill out a new form when your name or address changes or when the name or address of your beneficiary changes. 5. You must complete the form in duplicate and file it with your employing agency. To be valid, your agency must receive the completed form prior to your death. The duplicate will be annotated and returned to you as evidence that the original was received and filed with your agency. We suggest that you file the duplicate with your important papers. 6. You can cancel any prior Designation of Beneficiary form without naming a new beneficiary by completing a new form and inserting “Cancel prior designations” in the space provided for the name of beneficiary. This will change the payment to the order of payment described under “Order of Precedence.” 7. This designation remains valid unless (a) you change or revoke it, (b) you transfer to another agency, or (c) you leave and then are reemployed by the Federal Government. If you are covered by (b) or (c), you must fill out a new form if you want to change the order of payment described under “Order of Precedence.” NOTE: If this form is not available, any designation, change or cancellation of beneficiary that is witnessed and filed according to these instructions will be valid. This form is not to be confused with Standard Form 2808, Designation of Beneficiary, Civil Service Retirement System, Standard Form 2823, Designation of Beneficiary, Federal Employees’ Group Life Insurance Program, or Standard Form 3102, Designation of Beneficiary, Federal Employees Retirement System. Privacy Act Statement Solicitation of this information is authorized by the Code of Federal Regulations, Part 178, Subpart B. The information you furnish will be used to determine the amount, validity, and the person(s) entitled to the unpaid compensation of a deceased Federal employee. The information may be shared and is subject to verification, via paper, electronic media, or through the use of computer matching programs to obtain information necessary for determination of entitlement under this program or to report income for tax purposes. It may also be shared and verified, as noted above, with law enforcement agencies when they are investigating a violation or potential violation of the civil or criminal law. Public Law 104-134 (April 26, 1996) requires that any person doing business with the Federal government furnish a Social Security Number or tax identification number. This is an amendment to title 31, Section 7701. Failure to furnish the requested information may delay or make it impossible for us to determine eligibility of payments. U.S. Office of Personnel Management 5 CFR 178 Standard Form 1152 (Reverse Part 2) Revised June 2002 American LegalNet, Inc. www.FormsWorkFlow.com