"Designation of Beneficiaries Form"

Designation of Beneficiaries Form is a 1-page legal document that was released by the U.S. Department of Justice and used nation-wide.

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Designation of Beneficiaries Form
for U.S. Department of Justice Public Safety Officers’ Benefits (PSOB) Program
WHO RECEIVES PSOB BENEFITS IF A CLAIM IS APPROVED?
Benefits are paid to survivors according to the following criteria:
1.
If there is a spouse and no child* or children, all to the spouse.
2. If there is a spouse and child or children, one-half to the spouse and one-half to
the child or children in equal shares.
3. If no spouse, and children only, all to the child or children in equal shares.
PURPOSE
4. If no spouse or children, then to the individual(s) designated by the officer in the
OF THIS
most recently executed designation of (PSOB) beneficiary on file with the
FORM
officer’s agency at the time of the officer’s death. If no PSOB designation, then
to the individual(s) designated by the officer on the most recently executed life
insurance policy on file with the officer’s agency at the time of death.
5. If no spouse, children, PSOB designation, or life insurance beneficiary, then to the
officer’s surviving parents in equal shares.
6. If none of the above, then to the officer’s children who would receive the benefit
but for age (i.e., adult children.)
*”Child” is defined as any natural, illegitimate, adopted or posthumous child or stepchild of
a deceased public safety officer who, at the time of the officer’s death, is 18 years old or
under; 19-22 and a full-time student; or 19 and older, and incapable of self-support due to a
physical or mental disability.
This form is for use in declaring a beneficiary for any PSOB benefits that your survivors may be eligible for in the
event of your death. The circumstances in which the beneficiaries identified here might be eligible for the PSOB
benefit identified in Step 4 above and would not apply if there is an eligible surviving spouse and/or children.
Should you wish to complete this form, it must be retained with official department records.
I, _______________________________ (print full name), as a member of _________________________________
(print agency name), hereby designate the following beneficiary(s) for an PSOB benefits that may be paid in the
event of my death:
Name
Percent
Address
Relationship
(must total 100)
Public Safety Officer signature: ______________________________________
Date: ____/____/____
Witness signature: ________________________________________________
Date: ____/____/____
Designation of Beneficiaries Form
for U.S. Department of Justice Public Safety Officers’ Benefits (PSOB) Program
WHO RECEIVES PSOB BENEFITS IF A CLAIM IS APPROVED?
Benefits are paid to survivors according to the following criteria:
1.
If there is a spouse and no child* or children, all to the spouse.
2. If there is a spouse and child or children, one-half to the spouse and one-half to
the child or children in equal shares.
3. If no spouse, and children only, all to the child or children in equal shares.
PURPOSE
4. If no spouse or children, then to the individual(s) designated by the officer in the
OF THIS
most recently executed designation of (PSOB) beneficiary on file with the
FORM
officer’s agency at the time of the officer’s death. If no PSOB designation, then
to the individual(s) designated by the officer on the most recently executed life
insurance policy on file with the officer’s agency at the time of death.
5. If no spouse, children, PSOB designation, or life insurance beneficiary, then to the
officer’s surviving parents in equal shares.
6. If none of the above, then to the officer’s children who would receive the benefit
but for age (i.e., adult children.)
*”Child” is defined as any natural, illegitimate, adopted or posthumous child or stepchild of
a deceased public safety officer who, at the time of the officer’s death, is 18 years old or
under; 19-22 and a full-time student; or 19 and older, and incapable of self-support due to a
physical or mental disability.
This form is for use in declaring a beneficiary for any PSOB benefits that your survivors may be eligible for in the
event of your death. The circumstances in which the beneficiaries identified here might be eligible for the PSOB
benefit identified in Step 4 above and would not apply if there is an eligible surviving spouse and/or children.
Should you wish to complete this form, it must be retained with official department records.
I, _______________________________ (print full name), as a member of _________________________________
(print agency name), hereby designate the following beneficiary(s) for an PSOB benefits that may be paid in the
event of my death:
Name
Percent
Address
Relationship
(must total 100)
Public Safety Officer signature: ______________________________________
Date: ____/____/____
Witness signature: ________________________________________________
Date: ____/____/____