Death Benefit Designation Form A 01 16 2008 DBT_Beneficiary_Designation_Form_A_Jan_08 DBT Beneficiary Jan 08
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LAW EFORCEMET OFFICERS AD FIRE FIGHTERS DEATH BEEFITS TRUST
BEEFICIARY DESIGATIO FORM
FOR:
DEATH BENEFITS OF COVERED PUBLIC EMPLOYEES KILLED IN THE LINE OF DUTY, PURSUANT TO MCA § 45-2-1, AS AMENDED.
Pursuant to the provisions of Mississippi Code Annotated Section 45-2-1, as amended by Chapter 429, Senate Bill 2688, Mississippi Legislature,
2007 Regular Session, effective August 1, 2006, I acknowledge and understand that the Mississippi Department of Public Safety is responsible for
management of the trust fund and disbursement of the $65,000 death benefit authorized under the statute when a covered individual, while engaged in the
performance of the person’s official duties, is accidentally or intentionally killed or receives accidental or intentional bodily injury that results in the loss of the
covered individual’s life, provided that the killing is not the result of suicide and that the bodily injury is not intentionally self-inflicted.
According to the amended statute, the death benefit payment shall be made to the beneficiary who was designated in writing by the covered
individual, as signed by the covered individual and delivered to the employer during the covered individual’s lifetime. If no such designation is made, then the
payment shall be made to the surviving child or children and spouse in equal portions, and if there is no surviving child or spouse, then to the individual’s
parent or parents. If a beneficiary is not designated and there is no surviving child, spouse or parent, then the payment shall be made to the covered individual's
estate.
The death benefit payment is in addition to any workers' compensation or pension benefits and is exempt from the claims and demands of creditors of
the covered individual.
For purpose of compliance with the statute, the following information identifies me and accordingly, designates my beneficiaries:
NAME OF COVERED INDIVIDUAL:
___________________________ ______________________ _______________________________
First Middle Last
SOCIAL SECURITY NUMBER: DATE OF BIRTH:
___________________________ ______________________
DESIGNATED BENEFICIARY (BENEFICIARIES):
BENEFICIARY NAME: DATE OF BIRTH: SOCIAL SECURITY NUMBER: RELATIONSHIP:
___________________________ _______________ ___________________________ _______________________
___________________________ _______________ ___________________________ _______________________
___________________________ _______________ ___________________________ _______________________
___________________________ _______________ ___________________________ _______________________
This signed document designates the above named person(s) as my beneficiaries for purpose of receiving MCA § 45-2-1 death benefits:
_______________________________________________ COVERED INDIVIDUAL’S SIGNATURE ________________ DATE OF SIGNATURE
A C K O W L E D G M E T
STATE OF MISSISSIPPI
COUNTY OF _________
PERSONALLY APPEARED BEFORE ME, the undersigned authority in and for the said county and state, on this _____ day of _____________,
20____, within my jurisdiction, the within named ____________________________________, who acknowledged that they executed and delivered the above
and foregoing instrument for the purposes contained therein.
In witness whereof, I hereunto set my hand and official seal.
_____________________________________
Notary Public
SEAL
My Commission Expires:_________________
FORM PREPARED UPO REQUEST:
MISSISSIPPI DEPARTMET OF PUBLIC SAFETY
R. STEVEN COLEMAN, ATTORNEY, SR.
DIVISION OF PUBLIC SAFETY PLANNING
MISSISSIPPI BAR # 6365 3750 I-55 NORTH FRONTAGE ROAD
JACKSON, MISSISSIPPI 39211
Revised: 01/16/2008 [a:\law & fire.2007 Am. wpd. RSC]
FORM “A”
TELEPHONE: (601) 987-4990
