Form approved OMB No. 3206-0142 Designation of Beneficiary Civil Service Retirement System Important: Read all instructions before you use this form. Civil Service Retirement System A. Identification Name (last, first, middle) Place an "X" in the block that applies to you. Date of birth (mm/dd/yyyy) Social Security Number An employee Retired or an applicant for retirement Former employee eligible for retirement in the future If you are retired, give your claim number. CSA Department or agency in which presently employed (or former department or agency): Department or agency Bureau Division I, the person identified above, designate the beneficiary or beneficiaries named below to receive any lump-sum benefit which may become payable under the Civil Service Retirement System (CSRS) after my death. I understand that this designation of beneficiary will not affect the rights of any survivors who may qualify for annuity benefits after my death, cancels any previous designation of beneficiary, and remains in effect until I cancel it in writing. Location (city, state and ZIP code) I direct, unless otherwise indicated below, that if more than one beneficiary is named, the share of any beneficiary who may predecease me or who may be disqualified for any other reason shall be distributed equally among the stated beneficiaries or entirely to the survivor. If none of the beneficiaries are alive and eligible to receive payment when a lump sum becomes payable, this designation is void and payment will be made according to the order of precedence set by law. B. Information Concerning The Beneficiaries (See Examples on the reverse of Part 1. Type or print clearly.) First name, middle initial, and last name of each beneficiary n Date of designation (mm/dd/yyyy) Address (including ZIP code) of each beneficiary o Relationship to you n Share to be paid to each beneficiary Shares designated must equal 100%. Your signature C. Witnesses (A witness is not eligible to receive payment as a beneficiary.) We, the undersigned, certify that the person identified in A. above signed in our presence. Signature of witness Address (including ZIP code) Signature of witness Address (including ZIP code) n We will pay to the person you designate, even if that person's name or relationship to you changes after you file this designation. For example, suppose you designate your spouse and then you two divorce and you marry someone else. We will pay any lump sum to your former spouse unless you submit another designation to cancel prior designations or to designate who we are to pay. o We will write to the address you provide here to contact the person you designate. However, that person is obligated to get in touch with us after your death to ask us to make payment. Type or print your return address so that we can return a copy for your file. Your designation is not effective until OPM receives and certifies it. Mail both copies of your designation of beneficiary to: U.S. Office of Personnel Management Retirement Operations Center P.O. Box 45 Boyers, PA 16017-0045 U.S. Office of Personnel Management 5 CFR 831 Part 1 - Original Standard Form 2808 Revised December 2008 Previous editions are not usable American LegalNet, Inc. www.FormsWorkFlow.com Important - The filing of this form will completely cancel any Civil Service Retirement System Designation of Beneficiary you may have filed before this date. Be sure to name in this form all persons you wish to designate as beneficiaries of any lump sum payable at your death. Examples 1. How to Designate One 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" as the name of the 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 Relationship to you Share to be paid to each beneficiary n 100 % Niece 2. How to Designate More Than One Beneficiary (Be sure that the shares to be paid to the several beneficiaries add up to 100 percent.) Address (including ZIP code) of each beneficiary First name, middle initial, and last name of each beneficiary Relationship to you Share to be paid to each beneficiary Alice M. Long 509 Canal Street Red Bank, NJ 07701 Aunt Joseph P. Brady 360 Williams Street Red Bank, NJ 07701 Nephew 25 % Catherine L. Rowe 792 Broadway Whiting, IN 46394 Mother 50 % o 25 % 3. How to Designate A Contingency First name, middle initial, and last name of each beneficiary John M. Parrish, if living Otherwise to: Susan A. Parrish Address (including ZIP code) of each beneficiary Relationship to you 810 West 180th Street New York, NY 10033 Father 810 West 180th Street New York, NY 10033 Sister Share to be paid to each beneficiary n 100 % 100 % 4. How to Cancel 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 to you Share to be paid to each beneficiary Cancel prior designations n "All" would also be acceptable. o "One fourth," "one half," etc., would also be acceptable. Standard Form 2808 Revised December 2008 Reverse of Part 1 American LegalNet, Inc. www.FormsWorkFlow.com Instructions Use this form ONLY if you are or were covered by the Civil Service Retirement System. If any portion of your service was under the Federal Employees' Retirement System, use Standard Form (SF) 3102. This Designation of Beneficiary form is used to designate who is to receive a lump-sum payment which may become payable after your death. It does not affect the right of any person who is eligible for survivor annuity benefits. Do not confuse this form with designation forms used for other types of benefits: SF 2823, Designation of Beneficiary, Federal Employees' Group Life Insurance Program; SF 3102, Designation of Beneficiary, Federal Employees' Retirement System; TSP-3, Federal Retirement Thrift Savings Plan Designation of Beneficiary; or SF 1152, Designation of Beneficiary, Unpaid Compensation of Deceased Civilian Employee. Do not fill out this form until you have read the information and instructions below. Important - The filing of this form will completely cancel any Designation of Beneficiary under the Civil Service Retirement System you may have previously filed. Be sure to name in this form all persons you wish to designate as beneficiaries of any lump sum payable at your death. Order of Precedence 4. You do not need to make a designation if you are satisfied with the order of precedence the law provides and you do not have a certified designation on file. That order of precedence follows: A witness to a designation of beneficiary is not eligible to receive payment as a beneficiary. 5. You cannot change or cancel a designation of beneficiary in a letter or in a last will or testament unless it is signed, witnessed, and filed as described in paragraph 3. 6. A designation of beneficiary remains in effect until (1) you cancel it by filing a new designation or (2) you receive a refund of your retirement deductions before retirement. To inform us if the name or address of a beneficiary changes, file a new designation of beneficiary. It may be important to file a new designation if your family situation changes. 1. To your widow or widower. 2. If your widow(er) is deceased, to your child or children, with the share of any deceased child distributed equally among 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 executor or administrator of your estate. 5. If none of the above, to the next of kin under the laws of the State in which you live at the time of your death. Completing the Designation Form 1. The examples printed on the back of the first page of this form may be helpful to you in naming a beneficiary or canceling a prior designation of beneficiary. Payment of a lump sum will be made to the first person or persons listed above who are alive on the day you die. 2. If you designate more than one beneficiary, be sure that the shares to be paid add up to 100 percent. Do not use dollar amounts to indicate the shares. Designating a Beneficiary 3. If you wish to designate more than four persons in Part B, use a blank sheet of paper which you will attach to the form. Print your name and date of birth at the top of the attachment and provide the information required in Part B for each beneficiary. Your signatures on the form and on the attachment must be witnessed by the same two people. The witnesses must sign both the form and the attachment. 4. Complete the form in duplicate. Type or print all entries except signatures. 5. Do not erase or alter entries. 1. You can designate any person, firm, corporation, or legal entity as your beneficiary. 2. You can change your beneficiary at any time, without the knowledge or consent of a previous beneficiary, and this right cannot be waived or restricted. 3. A designation of beneficiary must be in writing, signed, and witnessed. To be valid the designation must be received and certified by the Office of Personnel Management before your death. Privacy Act Statement Solicitation of this information is authorized by the Civil Service Retirement law (Chapter 83, title 5, U.S. Code). The information you furnish will be used to determine who will receive a lump-sum benefit in the event of your death. The information may be shared and is subject to verification, via paper, electronic media, or through the use of computer matching programs, with national, state, local or other charitable or social security administrative agencies in order to determine benefits under their programs, to obtain information necessary for determination of benefits 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 civil or criminal law. Executive Order 9397 (November 22, 1943) allows Federal agencies to use the Social Security Number as an individual identifier to distinguish between people with the same or similar names. Failure to furnish your Social Security Number may make it impossible for us to associate this designation of beneficiary with your records. Public Burden Statement We think providing this information takes an average of 15 minutes per response to complete, including the time for reviewing instructions, getting the needed data, and reviewing the completed form. Send comments regarding our estimate or any other aspect of SF 2808, including suggestions for reducing completion time, to the Office of Personnel Management (OPM), OPM Forms Officer (3206-0142), Washington, D.C. 20415-7900. The OMB number 3206-0142 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed. Standard Form 2808 Revised December 2008 Reverse of Part 2 American LegalNet, Inc. www.FormsWorkFlow.com