BENEFICIARY DESIGNATION FORM

For Death Benefits From the IBEW Benefit Fund

[“A” Members of the IBEW Only]

Note: If you do not designate a beneficiary, your death benefits will be paid in the following order of preference

1. To your Spouse, or if none; 2. To your children in equal shares, or if none; 3. To your parents in equal shares, or if none; 4. To your estate.

If the foregoing sequence is acceptable to you, no further action is necessary. If the order of preference listed above is unacceptable, please proceed with the completion of this form, affix first class postage, and mail to the International Secretary. You may name either an individual(s) or on organization to receive this death benefit payment

Members Name ___________________________________L.U.# _____________ Card # ___________________

(Please Print)

Social Security or Social Insurance # ___________________________________

PLEASE MAKE PAYMENT TO MY BENEFICIARY OR BENEFICIARIES EQUALLY AS FOLLOWS

FIRST NAME                             INIT.              LAST NAME                                      RELATIONSHIP                              AGE

1. ___________________________________________________________________________________________________________

2. ___________________________________________________________________________________________________________

3. ___________________________________________________________________________________________________________

OR TO MY CONTINGENT BENEFICIARY OR BENEFICIARIES EQUALLY AS FOLLOWS:

FIRST NAME                               INIT.               LAST NAME                                   RELATIONSHIP                              AGE

1. ___________________________________________________________________________________________________________

2. ___________________________________________________________________________________________________________

3. ___________________________________________________________________________________________________________

OR

Name and Address of Organization, Institution or Trust__________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

MEMBER'S SIGNATURE __________________________________________________________

DATE __________________________________________________

Member's signature must be certified by a responsible local union official or a notary public.

Sworn to before me this ________________________ day of, ______________________ 20 __________________

Notary or Local Union Official _____________________________________________________________________

Mail Form to: Jeremiah J. O’ Conner, IBEW Secretary-Treasurer 1125 15th Street N. W.  Washington, D.C. 20005 (Attn: Beneficiary Records Dept.)

Form 124 Rev. Jan. 1992