SAN BERNARDINO COMMUNITY COLLEGE DISTRICT
WARRANT RECIPIENT DESIGNATION
FORM: HR-WD-EC / REV. JAN 2013/ P:\SHARE\WIKI FORMS\WIKI FORMS - WORD DOC'S\WARRANT DESIGNATION-EMERGENCY CONTACT.HR-
WD-EC.docx
AS PROVIDED IN SECTION 53245 OF THE CALIFORNIA GOVERNMENT CODE, IN THE EVENT OF MY DEATH, I HEREBY
DESIGNATE THE FOLLOWING PERSON
(S) TO RECEIVE ANY AND ALL WARRANTS PAYABLE TO ME ISSUED BY THE SAN
BERNARDINO COMMUNITY COLLEGE DISTRICT.
1. Name of Designee: ________________________________________ Relationship: ___________________
Address: ____________________________________________ Phone Number: ___________________
____________________________________________
2. Name of Designee: ________________________________________ Relationship: ___________________
Address: ____________________________________________ Phone Number: ___________________
____________________________________________
EMERGENCY CONTACT INFORMATION
CHECK here if information is same as above
1. Name: ________________________________________ Relationship: ______________________
Address: ____________________________________________ Phone Number: ___________________
____________________________________________
2. Name: ________________________________________ Relationship: ______________________
Address: ____________________________________________ Phone Number: ___________________
____________________________________________
This designation form cancels and replaces any designation previously signed for this purpose and shall remain in
effect until cancelled by me in writing. It is expressly understood and agreed that the district is not obligated to
deliver said warrant(s) to the person(s) listed above unless the person claims such warrants from the district and
provides sufficient proof of identity.
Printed Name: ________________________________________
Employee Signature: ___________________________________ Date: ___________________
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