Designation of Beneficiary 

Unpaid Compensation of Deceased Civilian Employee Important: 

Read all instructions before 

filling in this form 

A. Identification 

Name (Last, first, middle) Date of birth (mm, dd, yyyy) Social Security Number 

Department or agency in which presently employed (or former department or agency) : 

Department or agency Bureau Division Location (City, state and ZIP code) 

I, the employee named above, canceling any and all previous Designations of Beneficiar y heretofore made by me, do now 

designate the beneficiary or beneficiaries named below to receive any unpaid compensation due and payable after my death. 

I understand that this Designation of Beneficiary relates solely to money due as defined in 5 U.S.C. 5581, 5582, 5583, and in no 

way will affect the disposition of any benefit which may become payable under the Retirement or Group Life Insurance Acts 

applicable to my Government service. I further understand that this Designation of Beneficiary will remain in full force and effect 

until (1) I expressly change or revoke it in writing, (2) I transfer to another agency, or (3) I am reemployed by the same or another 

department or agency of the Government. 

B. Information Concerning The Beneficiaries (See Examples of Designations): 

First name, middle initial, and last 

name of each beneficiary 

Address (Including ZIP code) of 

each beneficiary 

Relationship Share to be paid to 

each beneficiary 

Date of designation (mm, dd, yyyy) Your signature 

Total = % 

C. Witnesses (A witness is not eligible to receive payment as a beneficiary): 

We, the undersigned, certify that this statement was signed in our presence. 

Signature of witness Number and street City, state and ZIP code 

Signature of witness Number and street City, state and ZIP code 

Receiving agency certification 

I have reviewed this designation and certify that the designated shares total 100% and that no witnesses are designated as beneficiaries. 

Date received Signature Date 

Type or print your return address to insure return 

U.S. Office of Personnel Management All Previous editions Standard Form 1152 Part 1 - Original 5 CFR 178 NSN 7540-00-634-4340 are not usable. Revised September 2011 
 

 

Important - The filing of this form will completely cancel any Designation of Beneficiary you may have previously filed. Be sure to name 

in this form all persons you wish to designate as beneficiaries of any unpaid compensation payable at your death. 

Examples of Designations 

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” in the beneficiary column. 

First name, middle initial, and last 

name of each beneficiary 

Address (Including ZIP code) of 

each beneficiary 

Relationship Share to be paid to 

each beneficiary 

Mary E. Brown 214 Central Avenue 

Muncie, IN 47303 

Domestic Partner 100% 

2. HOW TO DESIGNATE MORE THAN ONE Be sure that the shares to be paid to the several beneficiaries add up to 100 percent. 

First name, middle initial, and last 

name of each beneficiary 

Address (Including ZIP code) of 

each beneficiary 

Relationship Share to be paid to 

each beneficiary 

Alice M. Long 509 Canal Street 

Red Bank, NJ 07701 

Aunt 25% 

Joseph P. Brady 360 Williams Street 

Red Bank, NJ 07701 

Nephew 25% 

Catherine L. Rowe 792 Broadway 

Whiting, IN 46394 

Mother 50% 

3. HOW TO DESIGNATE A CONTINGENT BENEFICIARY 

First name, middle initial, and last 

name of each beneficiary 

Address (Including ZIP code) of 

each beneficiary 

Relationship Share to be paid to 

each beneficiary 

John M. Parrish, if living 810 West 180th Street 

New York, NY 10033 

Father 100% 

Otherwise to: Susan A. Parrish 810 West 180th Street 

New York, NY 10033 

Sister 100% 

4. HOW TO CANCEL A DESIGNATION OF BENEFICIARY 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 Share to be paid to 

each beneficiary 

Cancel prior designations 

U.S. Office of Personnel Management Standard Form 1152 (Reverse of Part 1) 

5 CFR 178 Revised September 201
 

 

Designation of Beneficiary 

Unpaid Compensation of Deceased Civilian Employee Important: 

Read all instructions before 

filling in this form 

A. Identification 

Name (Last, first, middle) Date of birth (mm, dd, yyyy) Social Security Number 

Department or agency in which presently employed (or former department or agency) : 

Department or agency Bureau Division Location (City, state and ZIP code) 

I, the employee named 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 after my death. 

I understand that this Designation of Beneficiary relates solely to money due as defined in 5 U.S.C. 5581, 5582, 5583, and in no 

way will affect the disposition of any benefit which may become payable under the Retirement or Group Life Insurance Acts 

applicable to my Government service. I further understand that this Designation of Beneficiary will remain in full force and effect 

until (1) I expressly change or revoke it in writing, (2) I transfer to another agency, or (3) I am reemployed by the same or another 

department or agency of the Government. 

B. Information Concerning The Beneficiaries (See Examples of Designations): 

First name, middle initial, and last 

name of each beneficiary 

Address (Including ZIP code) of 

each beneficiary 

Relationship Share to be paid to 

each beneficiary 

Date of designation (mm, dd, yyyy) Your signature 

Total = % 

C. Witnesses (A witness is not eligible to receive payment as a beneficiary): 

We, the undersigned, certify that this statement was signed in our presence. 

Signature of witness Number and street City, state and ZIP code 

Signature of witness Number and street City, state and ZIP code 

Receiving agency certification 

I have reviewed this designation and certify that the designated shares total 100% and that no witnesses are designated as beneficiaries. 

Date received Signature Date 

Type or print your return address to insure return

U.S. Office of Personnel Management Part All previous editions are Standard Form 1152 2 - Employee Copy 5 CFR 178 NSN 7540-00-634-4340 not usable. Revised September 2011 
	 

	 

	 

	 

	 

	 

	 

 

IMPORTANT NOTICE – ORDER OF PRECEDENCE 


If there is no designated beneficiary alive at the time of your death, any unpaid compensation owed you (that becomes payable 

after you die) will be paid to the first person or persons in the order listed below who are alive on the date that entitlement to 

the payment occurs. 

1. To your widow or widower. 

2. If neither of the above, to your child or children in equal shares. The share of an y deceased child is distributed to 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 duly appointed legal representative of your estate. If there is none, to the person or persons 

entitled under the laws of the State or other domicile where you lived. 

You do not need to designate a beneficiary unless you want to name some person or persons not listed above or you want 

the payment to be made in a different order. 

INSTRUCTIONS 

1. The examples on the back of the first page of this form may be helpful to you in filling out this form. 

2. Except for signatures, you should type or print all entries in ink (typing is preferred). You should use this form for any 

designation of beneficiary or beneficiaries. The form must be signed and witnessed. 

3. The form should be free of erasures or alterations to avoid a possible legal contest after your death. 

4. You do not need to fill out a new form when y our name or address changes or when the name or address of your 

beneficiary changes. 

5. You must complete the form in duplicate and file it with your employing agency. To be valid, your agency must receive the 

completed form prior to your death. The duplicate will be annotated and returned to you as evidence that the original was 

received and filed with your agency. We suggest that you file the duplicate with your important papers. 

6. You can cancel any prior Designation of Beneficiary form without naming a new beneficiary by completing a new form and 

inserting “Cancel prior designations” in the space provided for the name of beneficiary. This will change the payment to 

the order of payment described under “Order of Precedence.” 

7. This designation remains valid unless (a) you change or revoke it, (b) you transfer to another agency, or (c) you leave and 

then are reemployed by the Federal Government. If you are covered by (b) or (c), you must fill out a new form if you want 

to change the order of payment described under “Order of Precedence.” 

NOTE: If this form is not available, any designation, change or cancellation of beneficiary that is witnessed and filed according 

to these instructions will be valid. 

This form is not to be confused with Standard Form 2808, Designation of Beneficiary, Civil Service Retirement System, 
 


Standard Form 2823, Designation of Beneficiary, Federal Employees’ Group Life Insurance Program, or 
 


Standard Form 3102, Designation of Beneficiary, Federal Employees Retirement System. 
 


Privacy Act Statement 

Solicitation of this information is authorized by the Code of Federal Regulations, Part 178, Subpart B. The information you 

furnish will be used to deter mine the amount, validity, and the person(s) entitled to the unpaid compensation of a deceased 

Federal employee. The information may be shared and is subject to verification, via paper, electronic media, or through the 

use of computer matching programs to obtain information necessary for determination of entitlement 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 the civil or criminal law. Public Law 104-134 (April 26, 1996) requires that 

any person doing business with the Federal government furnish a Social Security Number or tax identification number. This 

is an amendment to title 31, Section 7701. Failure to furnish the requested information may delay or make it impossible for us 

to determine eligibility of payments. 

U.S. Office of Personnel Management Standard Form 1152 (Reverse Part 2) 

5 CF Revised September 2011