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# DESIGNATION OF BENEFICIARYFEDERAL EMPLOYEES GROUP LIFEINSURANCE PROGRAMStandard Form No. 44January 1968,U.S. Civil Service CommissionFPM Supplement 990-134-106INFORMATION CONCERNING THE INSURED:NAME(Last) (First) (Middle) DATE OF BIRTH (Month, day, year)IMPORTANTRead instructionson back of duplicatebefore filling in this formPLACE AN "X" IN THE APPROPRIATE BOX BELOW TO SHOW WHETHER YOU ARE:[ ] AN EMPLOYEE[ ] RETIRED OR AN APPLICANT FOR RETIREMENT[ ] RECEIVING FEDERAL EMPLOYEES COMPENSATION BENEFITS OR AN APPLICANT FOR SUCH BENEFITSIF YOU ARE RETIRED OR RECEIVING FEDERAL EMPLOYEES COMPENSA-TION GIVE YOUR FINL "CSL"A" or "X" NUMBERDEPARTMENT OR AGENCY IN WHICH PRESENTLY EMPLOYED (If retired, former department or agency):(Department or agency) (Bureau) (Location-City, State, and ZIP Code)(CSA, CSI, A. or X number)I, the individual identified above, canceling any and all previous Designations of Beneficiary under the Federal Employees Group Life Insurance Program heretofore made by me, do now designate the beneficiary or beneiciaries named I ow to receive any amount of LIFE INSURANCE and ACCIDENTAL DEATH INSURANCE due and payable at my death. I understand that this Designation of Beneficiary will remain in full force and effect, with respect to any amount payable, unless or until canceled by me in writing, or until such time as it is automatically canceled (see regulation "f" on reverse side of duplicate copy).INFORMATION CONCERNING THE BENEFICIARY OR BENEFICIARIES (SEE EXAMPLES OF DESIGNATIONS):| Type or print first name, middle initial, and last name of each beneficiary | Type or print address (including ZIP Code) of each beneficiary | Relationship | Share to be paid to each beneficiary || --------------------------------------------------------------------------- | -------------------------------------------------------------- | ------------ | ------------------------------------ ||                                                                             |                                                                |              |                                      ||                                                                             |                                                                |              |                                      ||                                                                             |                                                                |              |                                      |For each type of insurance (regular and optional): (1) I hereby direct, unless otherwise indicated above, that if more than one beneficiary is named, the share of any beneficiary who may predecease me shall be distributed equally among the surviving beneficiaries, or entirely to the survivor. (2) I understand that this Designation of Beneficiary shall be void if none of the designated beneficiaries is living at the time of my death.I hereby specifically reserve the right to cancel or change this Designation of Beneficiary at any time without knowledge or consent of the beneficiary.(Date of execution-month, day, year)WITNESSES TO SIGNATURE (A witness is ineligible to receive payment as a beneficiary):(Signature of witness)(Signature of witness)PRINT OR TYPE NAME AND ADDRESS (including ZIP Code) OF INSUREDTHIS SPACE RESERVED FOR RECEIVING AGENCY(Indicate date and by whom received)SEE REVERSE SIDE OF DUPLICATE COPY FOR INSTRUCTIONS ON WHERE TO FILE THESE FORMS.DO NOT FILE WITH THE OFFICE OF FEDERAL EMPLOYEES' GROUP LIFE INSURANCEDUPLICATE