WASHINGTON  STATEFIREFIGHTERS

SPOUSE AND ORPHAN’S FUND

P.O. Box 27·  Sumner  WA · 98390-0027 · (253) 445-9624

Board:  Tom Needham· Terry Miller·Lester Averill· Ed Johnson, Treasurer 

CHANGE OF BENEFICIARY FORM

Member’s Name _______________________________  ID # _________

Department ___________________________________

I am a member of the Spouse and Orphan’s Fund and want to make a change in my beneficiary.

Beneficiaries are limited to SPOUSE, CHILD, PARENT, ESTATE, LIVING TRUST, AND REGISTERED WASHINGTON STATE DOMESTIC PARTNER.

New Beneficiary _____________________________________________

Relationship (From above list) __________________________________

Address of beneficiary ________________________________________

                               _________________________________________

Signature of member __________________________________________

Date ______________________