Get Psob

Designation of Beneficiaries Form for U.S. Department of Justice Public Safety Officers Benefits PSOB Program WHO RECEIVES PSOB BENEFITS IF A CLAIM IS APPROVED Benefits are paid to survivors according to the following criteria 1. If there is a surviving spouse and no child or children all to the spouse. 2. If there is a spouse and child or children one-half to the spouse and one-half to the child or children in equal shares. 3. If no spouse and children only all to the child or children in equal shares. 4. If no spouse or children then to the individual s designated by the officer in the most recently executed designation of PSOB beneficiary on file with the officer s agency at the time of the officer s death. If no PSOB designation then to the individual s designated by the officer on the most recently executed life insurance policy on file with the officer s agency at the time of death. 5. If no spouse children PSOB designation or life insurance beneficiary then to the officer s surviving parents in equal shares. 6. If none of the above then to the officer s children who would receive the benefit but for age i*e* adult children. Child is defined as any natural illegitimate adopted or posthumous child stepchild of a deceased public safety officer who at the time of the officer s death is 18 years old or under 19-22 and a full-time student or 19 and older and incapable of selfsupport due to a physical or mental disability. This form is for use in declaring a beneficiary for any PSOB benefits that your survivors may be eligible for in the event of your death. The circumstances in which the beneficiaries identified here might be eligible for the PSOB benefit are identified in Step 4 above and would not apply if there is an eligible spouse or children* Should you wish to complete this form it must be retained with official departmental records. I print full name as a member of for any PSOB benefits that may be paid in the event of my death NAME ADDRESS RELATIONSHIP PERCENT must total 100 Officer signature Date // Notary State of County of Subscribed and sworn to before me a Notary Public in and for said County and State this day of Stamp or Seal Signature of Notary Public Printed Name of Notary Public. If there is a surviving spouse and no child or children all to the spouse. 2. If there is a spouse and child or children one-half to the spouse and one-half to the child or children in equal shares. 3. If no spouse and children only all to the child or children in equal shares. 4. If no spouse or children then to the individual s designated by the officer in the most recently executed designation of PSOB beneficiary on file with the officer s agency at the time of the officer s death. 3. If no spouse and children only all to the child or children in equal shares. 4. If no spouse or children then to the individual s designated by the officer in the most recently executed designation of PSOB beneficiary on file with the officer s agency at the time of the officer s death. If no PSOB designation then to the individual s designated by the officer on the most recently executed life insurance policy on file with the officer s agency at the time of death.