STATE OF ALASKA
DESIGNATION OF BENEFICIARY FOR UNPAID COMPENSATION
This form names the people you want to receive unpaid wage compensation in the event of your death while an employee of the State of Alaska. It can
also be used to change those names at any time. Your wishes may not be carried out as intended if the form is not completed correctly.
Employee Name Department
Employee ID Date of Birth
INITIAL AUTHORIZATION CHANGE
PRIMARY BENEFICIARY (IES)
CONTINGENT BENEFICIARY (IES)
TOTAL PRIMARY PERCENTAGE MUST EQUAL
TOTAL CONTINGENT PERCENTAGE MUST EQUAL
INSTRUCTIONS
1. You may designate one primary beneficiary who would be the sole beneficiary.
2. You may designate primary beneficiary(ies) and contingent beneficiary(ies). Primary beneficiaries receive the benefit first if you die. Contingent
beneficiaries receive the benefit if the primary beneficiary has died.
3. You may designate any number of beneficiaries to share in any manner you wish. Please designate the percentage to pay each beneficiary. The
total percentage of all Primary beneficiaries must equal 100% and the total of all Contingent beneficiaries must equal 100%. List each name
separately; attach additional forms if necessary.
4. If you are designating a minor (under 18 yrs of age) as your beneficiary, you must add the minor's date of birth (DOB).
5. Should you wish to change or alter your designation of beneficiary, be sure to complete a new form in its entirety.
6. This form must be witnessed by someone who can verify your identity and who is not your beneficiary.
Return this completed form to your Payroll Services Section or Agency HR Office, or you may send it directly to Dept. of Administration, Div. of
Finance, Payroll Section, P.O. Box 110204, Juneau AK 99811-0204.
Rev. 04/25/2012
