Fillable MR MS MRS MI Last Name First Name

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MR MS MRS MI Last Name First Name

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BENEFICIARY DESIGNATION FORM - USA
First Name
MI Last Name
Local Union Card Number Social Security Number
First Name MI Last Name
Relationship
First Name MI Last Name
Relationship
First Name MI Last Name
Relationship
If naming an individual, please complete this section and if you need additional beneficiaries attach Form No.124C.
For Death Benefits from the IBEW Pension Benefit Fund
Retired/Active "A" Members of the IBEW
MR
MS
MRS
MR
MS
MRS
MR
MS
MRS
Section A: Member's Information
Section B: Beneficiary Information
If naming an organization or trust, please complete this section
Name of Organization, Institution or Trust
Address (Street & Number)
City State Zip Code+4
Choose One:
Primary Contingent
Primary Contingent
Choose One:
Primary Contingent
Choose One:
Primary Contingent
Choose One:
Mail Completed Form to:
IBEW
900 7th Street, NW
Washington, DC 20001
Attn: Pension & Death Claims Dept
Form No. 124A Rev. 08/01/08
Member's Signature
Printed Name and Title of LU Official or Notary
Notary or Local Union Official's Signature
Today's Date (MM/DD/YYYY)
Today's Date (MM/DD/YYYY)
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MR
MS
MRS
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Additional Beneficiaries Form 124C
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MR MS MRS MI Last Name First Name

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Completed 14 January 2022

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