[104-10194-10026.pdf — page 217]
# DESIGNATION OF BENEFICIARYUNPAID COMPENSATION OFDECEASED CIVILIAN EMPLOYEEIMPORTANTRead instructions on back of duplicate before filling in this formINFORMATION CONCERNING THE EMPLOYEE:NAME:(Last) Phillips(First) David(Middle) AtleeDATE OF Birth (Month, day, year)October 31, 1922DEPARTMENT OR AGENCY IN WHICH EMPLOYEDI, the employee identified 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 under existing law after my death. I understand that this Designation of Beneficiary relates solely to Unpaid Compensation as defined in section 8 of the act of August 3, 1950, Public Law 636, and in nowise will affect the disposition of any benefit which may become payable under the Retirement Act applicable to my Government service. I further understand that this Designation of Beneficiary will remain in full force and effect, unless or until canceled by me in writing, so long as I am continuously employed in the above department or agency.INFORMATION CONCERNING THE BENEFICIARY OR BENEFICIARIES:| Type or print first name, middle initial, and last name of each beneficiary | Type or print address of each beneficiary       | Relationship | Share to be paid to each beneficiary || --------------------------------------------------------------------------- | ----------------------------------------------- | ------------ | ------------------------------------ || Maria I. Phillips                                                           | 8224 Stone Trail Drive Bethesda, Maryland 20034 | daughter     | one-fourth                           || David A. Phillips, Jr.                                                      | 8224 Stone Trail Drive Bethesda, Maryland 20034 | son          | one-fourth                           || Atlee Y. Phillips                                                           | 8224 Stone Trail Drive Bethesda, Maryland 20034 | daughter     | one-fourth                           || Christopher C. Phillips                                                     | 8224 Stone Trail Drive Bethesda, Maryland 20034 | son          | one-fourth                           |I hereby direct, unless otherwise indicated above, that, if more than one beneficiary is named, the share of any deceased beneficiary who may predecease me shall be distributed equally among the surviving beneficiaries, or entirely to the survivor. 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 any designation of beneficiary at any time in the manner and form prescribed by the Comptroller General of the United States, and without knowledge or consent of the beneficiary.1 December 1967(Date of execution-month, day, year)(Signature of employee)WITNESSES TO SIGNATURE:Margaret Lovice(Signature of witness)2400 So. Glebe Rd(Number and street)Arlington, Va 22206(City, zone number, and State)Elizabeth Ann Kelly(Signature of witness)8137 Prescott Dr(Number and street)Vienna, Va 22180(City, zone number, and State)PRINT OR TYPE NAME AND ADDRESS OF EMPLOYEEDavid A. Phillips8224 Stone Trail DriveBethesda, Maryland 20034THIS SPACE RESERVED FOR RECEIVING DATA OF EMPLOYING AGENCY05 DEC 1967(Indicate date and by whom received)