In the event of the death of the employee prior to payment of the benefits, but after the employee’s retirement has begun, the reimbursement benefits will be paid to the surviving spouse or dependents, if any. In the event no surviving spouse or dependents were identified, no additional benefits will be paid out.
Pursuant to the provisions of board policy 407.4, I hereby designate my spouse or dependents to be:
Name: _____________________________________________________
Relationship (check one): _____ Spouse _____ Dependent
Address: _____________________________________________________
City, State, Zip: ______________________________________________________
Signature: ______________________________________________________
Witness Signature: ______________________________________________________
Date: ______________________________________________________
__________________________________________________________________________________
Name: _____________________________________________________
Relationship (check one): _____ Spouse _____ Dependent
Address: _____________________________________________________
City, State, Zip: ______________________________________________________
Signature: ______________________________________________________
Witness Signature: ______________________________________________________
Date: ______________________________________________________
Attach additional pages as necessary.
