Introduction

I, [YOUR NAME], being of sound mind and legal capacity, do hereby declare and affirm the following preferences regarding the distribution of assets related to my life insurance policy:

Statements

1. Life Insurance Policy Details:

   • Policy Number: [POLICY NUMBER]

   • Insurance Company: [INSURANCE COMPANY NAME]

2. Beneficiary Designation:

   • Primary Beneficiary: [PRIMARY BENEFICIARY'S NAME]

   • Secondary Beneficiary (if applicable): [SECONDARY BENEFICIARY'S NAME]

   • Contingent Beneficiary (if applicable): [CONTINGENT BENEFICIARY'S NAME]

3. I hereby confirm that the above-named beneficiaries are my preferred recipients of the proceeds from the aforementioned life insurance policy upon my death. In the event that any of the designated primary beneficiaries are deceased or unable to receive the benefits, the proceeds shall pass to the secondary or contingent beneficiaries in the order specified.

4. I understand that this Preference Beneficiary Affidavit supersedes any prior beneficiary designations I may have made regarding the aforementioned life insurance policy.

5. I further affirm that I have full legal authority to make this designation and that it reflects my true and current intentions regarding the distribution of the life insurance proceeds.

6. This Preference Beneficiary Affidavit shall remain in effect unless modified or revoked by me in writing and duly executed according to the laws governing such documents.

I swear or affirm, under the penalty of perjury, that the contents of this affidavit are true and correct to the best of my knowledge.

Signatures

I declare under penalty of perjury under the laws of [STATE NAME] that the foregoing is true and correct.

[YOUR NAME]

Witnessed by:

[WITNESS' NAME]

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