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Change Of Beneficiary
Notice is hereby given to you to change the beneficiary on Policy No. [Number], of [Enumerate]. The policy was issued by [Name] hereinafter referred to as "Company".
Subject to the provisions attached and marked as Exhibit A, the beneficiary is to be changed from [Number], of [Address], to [Number], of [Address]. This request for change of beneficiary shall take effect as of the day it is signed, accepted, and recorded at the home office of the company. Any previous selection of a beneficiary is hereby revoked.
Name of Beneficiary
This Section for Notary:
STATE OF -------)
) ss: [date]
COUNTY OF ------)
On [Date] before me, [Name of Notary], notary, personally appeared [Name of Person(s) Involved], 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.
[Name of Notary Public]
My commission expires: [date]