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City of Kalispell Post Office Box 1997 - Kalispell, Montana 59903-1997 Telephone (406) 758-7750 Fax - (406) 758-7758 Designation of Person Authorized to Receive Decedent’s Warrants INSTRUCTIONS TO EMPLOYEES 1. Complete this form (typewritten or ink). 2. Show the designee’s full name. Examples: “Mary Jane Smith”, not Mrs. John E. Smith. 3. Show relationship of person being designated such as; wife, husband, daughter, son, mother, father, friend, etc. 4. Erasures or corrections may not be made in the writing of designee’s name. If an error has been made, complete a new form. 5. Sign the copy in ink. Submit the copy to the Personnel Department. A duplicate copy will be returned to you for your record or for you to give to the designee. 6. You may change your designation at any time by filing a new designation with the Personnel Department. 7. You may completely revoke a designation at any time by a letter to your employer signed by you (submit in duplicate). 8. Inform the Personnel Department or payroll clerk when a change occurs in your designee’s address. INSTRUCTIONS TO EMPLOYERS 1. Review the prepared form to insure that the employee has completed it properly. 2. Advise the employee that this form is a legally binding document. 3. Upon the decease of the employee, fill in the information on the right-hand margin; certifying officer should be the agency head or Personnel Officer. 4. Forward one copy of the form to the finance office. 5. Have your employees periodically review their designations. EMPLOYEE NAME (FIRST) (MIDDLE) (LAST) ADDRESS (STREET) (CITY) (STATE) (ZIP) SOCIAL SECURITY NUMBER DEPARTMENT DESIGNEE I hereby designate the following person who notwithstanding any other provision of law, shall be entitled upon my death to receive all City warrants, excluding warrants for payment of death benefits and refund of employee retirement contributions, that would have been payable to me as a result of my employment with the City of Kalispell had I survived: NAME (FIRST) (MIDDLE) (LAST) RELATIONSHIP ADDRESS (STREET) (CITY) (STATE) (ZIP) STIPULATION I hereby revoke any previous designation filed by me. If the above-named designee cannot be contacted within sixty (60) days after the date of my death, this designation shall be void. This designation will remain in full force and effect during my employment with the City of Kalispell until revoked in writing by me. This designation will automatically terminate on the date final payment is received as the result of said employment. SIGNATURE DATE FOR HR DEPARTMENT USE ONLY Reviewed by and date DESIGNATION DATE Revoked Automatically cancelled CC Payroll Revised 10/2016 S:\FORMS\ Decedent’s Warrants EMPLOYEE’S NAME (Last name first) DATE DECEASED CERTIFYING OFFICER