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Change Of Beneficiary Notice
BE IT ACKNOWLEDGED, that [Name] of [Address], is hereby designated beneficiary in and to a certain life insurance policy numbered [Number] and issued by [Name].
Said policy is dated [Date], the present death benefit payable is in the amount of [$------] on the life of the undersigned. This change of beneficiary acknowledgment terminates all prior designations of beneficiary heretofore made.
Please forward any necessary change of beneficiary forms.
Signed under seal this [Date].
This Section for Notary:
STATE OF ____________
COUNTY OF __________
On [Date] before me, [Name], personally appeared, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
WITNESS my hand and official seal.
[ ] Known
[ ] Unknown