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Designation of Beneficiary for Final Paycheck

Employee Name
Employee Address
I hereby designate the following as my beneficiary for my final paycheck and all accrued Paid Time Off (PTO) up to the net sum of $5,000 in the event of my death.(Required)
Beneficiary Name:
Beneficiary Address
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MM slash DD slash YYYY

IF YOU ARE MARRIED, YOU MUST OBTAIN SPOUSAL CONSENT ON THIS FORM TO THE DESIGNATION OF SOMEONE OTHER THAN YOUR SPOUSE AS YOUR SOLE PRIMARY BENEFICIARY.

CONSENT TO DESIGNATION OF NON-SPOUSE AS BENEFICIARY

I have read the above Designation of Beneficiary completed by my spouse and I hereby consent to the designation by my spouse of the above-mentioned beneficiary other than myself. I realize that as a result of my consent to this designation I waive my interest I might have in the assets subject to such designation. I realize that my consent applies only to this designation and does not apply to any future designation.

*SPOUSES SIGNATURE MUST BE WITNESSED BY A NOTARY PUBLIC

Name Typed
MM slash DD slash YYYY