WASHINGTON  STATEFIREFIGHTERS

SPOUSE AND ORPHAN’S FUND

3242 NE 3RD AVE #177 * CAMAS, WA 98607 * 360-624-6668

Board:  Tom Needham· Terry Miller·Lester Averill· Charlie Dawson, 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 ______________________