A. ORDER OF PRECEDENCE
(3 FAM 673.8-5)
4. Cancellation of a prior designation may be effected without naming a new
beneficiary by completing out a new DS-5002 and inserting in the space
provided for name of beneficiary the words, "Cancel Prior Designation."
(Section 815 (f) of the Foreign Service Act of 1980, as amended)
If there is no designated beneficiary living, any lump-sum benefit that becomes payable after
the death of a participant or a former participant will be payable to the first person or persons
listed below who are alive on the date the title to the payment arises:
1. To the surviving wife or husband of the participant.
2. If there is no surviving wife or husband, to the child or children of such participant
and descendants of deceased children by representation.
3. If none of the above, to the parents of such participant or the survivor of them.
4. If none of the above, to the duly appointed executor or administrator of the estate of such
participant.
5. If none of the above, to other next of kin of such participant as may be determined
by the Secretary in his/her judgement to be legally entitled thereto.
It is not necessary for any participant or former participant to designate a beneficiary
unless he/she wishes to name some person or persons not included above, or in a
different order.
B. PURPOSE OF DESIGNATING A BENEFICIARY
A designation of beneficiary is for lump-sum benefit purposes only, and does not affect
the right of any person who qualifies to receive survivor annuity benefits. Such benefits are
payable either by operations of law or as a result of an election made by a retiring participant.
C. INSTRUCTIONS
1. The examples printed may be helpful to you.
2. Type or print all entries except signatures.
3. This form must be completed and mailed to the appropriate Personnel Office.
The designation must be received prior to the death of the participant or former
participant to be valid.
5. This form is not intended as a will, and miscellaneous provisions such as
payment of just debts, payment of monthly installment plan, etc., will not be
recognized.
6. A designation free of erasures or alterations should be filed in order to avoid a
possible contest after death.
7. A copy will be returned to you as evidence that the original has been received
and filed. When you receive the duplicate, file it with your important papers.
D. REGULATIONS
1. The designation of beneficiary shall be in writing, signed and witnessed, and
received in the Department or Agency prior to the death of the participant.
2. No change or cancellation of beneficiary in a last will or testament, or in any
other document not witnessed and filed as required by these regulations, shall require
the Department or Agency to pay any alleged beneficiary other than the beneficiary
designated by the document witnessed and filed in accordance with these regulations.
Payment of the beneficiary so designated shall relieve the Department or Agency of
liability to any other claimant.
3. A witness to a designation of beneficiary is ineligible to receive payment as a
beneficiary.
4. A change of beneficiary may be made at any time and without the
knowledge or consent of the previous beneficiary unless the participant has
obligated himself/ herself under appropriate State law to do so. If the Department
or Agency is not notified of any such obligation before
payment is made, payment to the beneficiary designated in accordance with
the Department's or Agency's regulations, discharge the Department
or Agency of any further responsibility.
PRIVACY ACT STATEMENT
Title 5, U. S. Code, authorizes solicitation of this information. Your designation of
beneficiary will be used to determine who will receive a lump-sum benefit in the event of your
death.
Executive Order 9397
(November 22, 1943)
authorizes use of the Social Security
Number to distinguish between you and people with similar names. Furnishing your
Social Security Number, as well as the other date, is voluntary, but failure to do so may
result in your agency's inability to determine who is eligible to receive a lump-sum
benefit in the event of your death.
This information may be shared with national, State, local or other charitable, Social
Security Administrative or law enforcement agencies to determine and issue benefits
under their programs or, in the latter case, when they are investigating a violation or
potential violation of the civil or criminal law.
The filing of this form will completely cancel any Designation of Beneficiary under the Foreign Service Pension System or under the
Foreign Service Retirement and Disability System you may have previously filed. Be sure to name in this form all persons you wish
to designate as beneficiaries of any lump-sum payable at your death.
IMPORTANT -
Instruction Page 1 of 2
INSTRUCTIONS
(3 FAM 673.8-6)
DS-5002
10-2005
Designation of Beneficiary
IMPORTANT - The filing of this form will completely cancel any Designation of Beneficiary under the Foreign Service Pension System or under
the Foreign Service Retirement and Disability System you may have previously filed. Be sure to name in this form all persons you wish to
designate as beneficiaries of any lump sum payable at your death.
Examples of Designations
How to Designate One Beneficiary
How to Designate More than One Beneficiary
How to Designate a Contingent Beneficiary
(If beneficiary designated is not related to you, indicate "NONE" under "Relationship.)
How to Cancel a Designation of Beneficiary
Do not write name
as S.M. Jones or as
Mrs. George
L. Jones.
Be sure the shares
to be paid to the
beneficiaries add
up to 100%.
You may want to
cancel a beneficiary
you have named
if your circumstances
change and you want
the benefit
payable to your wife,
husband, children, or
parents in that order.
Type or print the first name, middle initial, and last
name of each beneficiary.
Type or pint the address of each beneficiary. Relationship
Share to be Paid to
Each Beneficiary.
SARAH M. JONES 22 Elm Street, Lima, Ohio Sister All
Type or print the first name, middle initial, and last
name of each beneficiary.
Type or print the address of each beneficiary. Relationship
Share to be Paid to
Each Beneficiary.
MARY A. SMITH
ANNA D. BROWN
HENRY G. BROWN
4902 Oak Street, Jason, North Dakota
50 Duke Street, Jason, North Dakota
50 Duke Street, Jason, North Dakota
Aunt
Cousin
None
One-half
One-fourth
One-fourth
DS-5002
Type or print the first name, middle initial, and last
name of each beneficiary.
CATHERINE J. ANDERSON, if living
JOHN L. JONES
91 Adams Place, Syracuse, New York
Relationship
Niece
Share to be Paid to
Each Beneficiary.
All
Type or print the address of each beneficiary.
Type or print the first name, middle initial, and last
name of each beneficiary.
Cancel Prior Designation
Type or print the address of each beneficiary. Relationship
Share to be Paid to
Each Beneficiary.
Instruction Page 2 of 2
NOTE:
1. Name
A. Information Concerning the Designator
Mail This Form To Your Agency's Personnel Office
3. Social Security Number 4. Date of this Designation
7. If Retired, Date of Retirement
I, the participant or former participant identified above, canceling any and all previous designations of beneficiary heretofore made by me under the Foreign Service Retirement and Disability System (FSRDS) or the Foreign Service Pension System (FSPS), do now
designate the beneficiary or beneficiaries named below to receive any lump-sum benefit (exclusive of voluntary deposits with accumulated interest as provided in Section 825 of the Foreign Service Act of 1980, as amended) which may become payable under FSRDS or
FSPS after my death. I understand that this designation of beneficiary will not affect the rights of any survivors who may qualify for annuity benefits after my death, and that this designation will remain in full force and effect unless and until canceled by me in writing.
B. Information Concerning the Beneficiary or Beneficiaries
Type or print the first name, middle initial,
and last name of each beneficiary.
Type or print the address of each beneficiary. Relationship
Share to be Paid to
Each Beneficiary
I hereby direct, unless otherwise indicated above, that, if more than one beneficiary is named, the share of any deceased beneficiary or beneficiaries who may die before a lump-sum benefit becomes payable shall be distributed
equally among the surviving beneficiaries, or entirely to the survivor. If none of the beneficiaries are alive when the lump-sum benefit becomes payable, this designation shall be void, and payment will be made according to the
order of precedence set by law.
C. Witness
(We, the undersigned, certify that this instrument was signed in our presence.)
Signature of Witness - Number and Street City, State and Zip Code
Signature of Designator -
Signature of Witness - Number and Street City, State and Zip Code
Print or type your name and address to Insure a return copy of this form. (Reserved for receiving stamp of employing
Department or Agency.)
SEE PRIVACY ACT STATEMENT
ON INSTRUCTION PAGE
WARNING
Do not fill out this form until
you have read the instructions.
U.S. Department of State
DESIGNATION OF BENEFICIARY
DS-5002
10-2005
(Formerly OF-137)
2. Date of Birth
6. Employing Department or Agency
(Last, First, MI.)
(mm-dd-yyyy)
(mm-dd-yyyy)
(mm-dd-yyyy)
DO NOT PRINT
DO NOT PRINT
DO NOT PRINT
(For Unpaid Annuity Up to the Time of Death)
5. Post of Assignment
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
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