General Secretariat

Human Resources Management Department

DESIGNATION, CHANGE OR REVOCATION OF BENEFICIARY

I,	born on

(Type or Print Surname, First, and Middle Name)	(Day, Month, Year)

revoking any and all previous designation of beneficiary made by me concerning funds that are or may be owed to me by the International Telecommunication Union, do now designate the beneficiary or beneficiaries named below, to whom I authorize and direct the International Telecommunication Union to pay at my death any money standing to my credit, with the exception of monies in the Joint Staff Pension Scheme :

NAME AND ADDRESS OF EACH BENEFICIARY

DATE OF BIRTH

RELATIONSHIP
SHARE TO BE PAID TO EACH BENEFICIARY

I, hereby direct, unless otherwise indicated above, that, if more than one beneficiary is named, the share of my deceased beneficiary or beneficiaries who may predecease me shall be distributed equally among surviving beneficiaries, or entirely to the survivor. If none survive me, then the entire amount shall go to my estate.

I hereby specifically reserve the right to revoke or change any beneficiary at any time in the manner and form prescribed by the International Telecommunication Union, and without the knowledge or consent of the beneficiary.

Date	_______________________________

Written Signature of Designator in Full

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WITNESSES

We the undersigned, having no financial interest in this subject matter, directly or indirectly, hereby certify that this instrument was subscribed in our presence and in the presence of each other on the _____________________________ (date) by the designator who is personally known to us.

_______________________________	_______________________________

Signature of Witness	Address of Witness

_______________________________	_______________________________

Signature of Witness	Address of Witness

o:\admin\nommes\modeles\distribu\beneficiary.doc

DESIGNATION, CHANGEMENT OU ANNULATION DE BENEFICIAIRE

dalhen

2013-11-27

Suedi Medina, Subira

ITU