Motlow State Community College
DESIGNATION OF BENEFICIARY
EMPLOYEE NAME:
____________________________________________________________
(Last) (First) (Middle) (Maiden)
SOCIAL SECURITY NO: __________________________
In accordance with the Tennessee Board of Regents procedure to disburse final compensation of
wages and benefits in the event of employee death, I hereby designate the beneficiary(ies) listed
below:
WAGES (TCA §30-2-103)
________________________________________________________________________
(Last Name) (First) (Middle) (Soc Sec. No) (Birthdate) (Sex) (Relationship)
ANNUAL LEAVE (TCA §8-50-808 and TBR POLICY 5:01:01:01, Section III.E.)
________________________________________________________________________
(Last Name) (First) (Middle) (Soc Sec. No) (Birthdate) (Sex) (Relationship)
SICK LEAVE (TCA §8-50-808 and TBR POLICY 5:01:01:01, Section VII)
________________________________________________________________________
(Last Name) (First) (Middle) (Soc Sec. No) (Birthdate) (Sex) (Relationship)
COMPENSATORY TIME (TCA §8-50-808)
________________________________________________________________________
(Last Name) (First) (Middle) (Soc Sec. No) (Birthdate) (Sex) (Relationship)
ESTATE _________________________________________
ADDRESS _________________________________________
I, the employee, revoke any previous beneficiary nominations and direct that the
foregoing designations supersede any previously filed.
EMPLOYEE SIGNATURE
________________________________________DATE__________________________
STATE OF TENNESSEE, COUNTY OF ________________________
__________________________ personally appeared before me on this the ____ day of
_______________, _____, who makes oath that (he) (she) executed the foregoing
instrument.
(NOTARY SEAL)
Notary Public: ________________________________
My Commission Expires: ________________________________
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