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3 Designation of Beneficiary Form 08-09-2015 AT

This document is a staff member's designation of beneficiaries form. The staff member designates her sister and father as beneficiaries, allocating 50% of proceeds to each. She revokes all previous designations and reserves the right to change beneficiaries at any time.

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Cecilia Gabriela Rodriguez Quintero
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8 views2 pages

3 Designation of Beneficiary Form 08-09-2015 AT

This document is a staff member's designation of beneficiaries form. The staff member designates her sister and father as beneficiaries, allocating 50% of proceeds to each. She revokes all previous designations and reserves the right to change beneficiaries at any time.

Uploaded by

Cecilia Gabriela Rodriguez Quintero
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Designation, Change, or Revocation of Beneficiary

To be completed by the STAFF MEMBER in front of a witness


To be submitted to the HRO / Personnel Administration and Payroll Section (PAPS)

First name, middle name, LAST NAME Index no: Date of Birth (dd/mm/yyyy)
I, Adriana Elizabeth Torres Hernandez 73007952 30/01/1990
Department / Division / Office Duty Station
CBI Ciudad de Mexico

hereby designate the person or persons named below as my beneficiary or beneficiaries under Staff Rule 1.6 in respect of
all amounts (salary, allowances and commutation of leave standing to my credit at the time of death. I understand that this
designation does not affect payment of death benefit or repatriation grant which are payable under the Staff Rules to a
surviving spouse and/or dependent child or children.
I also understand that, should I die as a result of an incident covered by the Malicious Act Insurance Policy, the proceeds
will be paid to the beneficiary / beneficiaries named below, unless I have a surviving spouse and/or dependent child or
children, in which case the proceeds of the policy will be paid to them.

Name of Beneficiary Date of Birth Sex Share to be


Address Phone No. Relationship
or Beneficiaries (dd/mm/yyyy) (M/F) paid* (%)
Santa Maria 322 Col.
Leticia Yaroslavi +52
14/09/1985 F Planta Solar, CP 37900, Hermana 50
Torres Hernandez 4441043085
San Luis de la Paz, Gto

Santa Maria 322 Col.


Genaro Planta Solar, CP 37900, +52
19/09/1964 M Padre 50
Torres Ojeda San Luis de la Paz, Gto 4686804527

*Total must add up to 100%

The share of any beneficiary who may predecease me shall be distributed equally among the surviving beneficiaries or go
entirely to the survivor. If none survive me, then the entire amount shall go to my estate.
I hereby revoke all previous designations or beneficiary made by me for this purpose and I reserve the right to revoke or
change any beneficiary without his or her knowledge or consent at any time in the manner and form prescribed by the
United Nations.

24-Enero-2023
Signature of Staff Member Date

Emergency Contact Relationship Phone No. Address


Leticia Yaroslavi Santa Maria 322 Col. Planta Solar, CP 37900,
Hermana +52 4441043085
Torres Hernandez San Luis de la Paz, Gto

WITNESS**
I, the undersigned, having no financial interest in this subject matter, directly or indirectly, hereby certify that this instrument
was signed in my presence by the staff member having designated his or her beneficiaries.

** Field Offices: HR/Admin Officer;


Headquarters: Administrative Assistant or or Snr Resource Manager of respective service/bureau
Designation of Beneficiary Form v.01/06/2018
Designation, Change, or Revocation of Beneficiary
To be completed by the STAFF MEMBER in front of a witness
To be submitted to the HRO / Personnel Administration and Payroll Section (PAPS)

Cecilia Gabriela Rodriguez Quintero Jefa de Departamento de Dictámenes 24 Enero 2023

Name (print) Title Date Signature

** Field Offices: HR/Admin Officer;


Headquarters: Administrative Assistant or or Snr Resource Manager of respective service/bureau
Designation of Beneficiary Form v.01/06/2018

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