Fill and Sign the Annuity Claim Form Ipipeline

Assignment by Beneficiary of an Interest in the Trust Formed for the Benefit of Beneficiary For value received, I, ________________________________________________ (Name of Beneficiary), of __________________________________________________ _________________________________________________________________________________________________ (street address, city, county, state, zip code), do hereby assign, transfer, and set over to ______________________________________________ (Name of Assignee), hereinafter called Assignee, of ______________________________ ________________________________________________________________________ ___________________________________ (street address, city, county, state, zip code), (e.g., all of my right, title, and interest in and to the income of the trust estate for the calendar year 2009) _______________________________________________________ ________________________________________________________________________ ________________________________________________________________________ of the Trust established by [e.g., Declaration of Trust of (name of trustor) dated (date) for the benefit of (name of beneficiaries)] _____________________________________ ________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________. To that extent I substitute Assignee as a Beneficiary of the above-referenced Trust.I further direct the Trustee of the Trust to remit directly to Assignee all monies and benefits accruing from the interest (i.e., the income for one year) now assigned and to consider Assignee a Beneficiary under the Trust to the extent of that interest, I irrevocably renounce every right of ownership and control over the sum assigned. In the event of the failure of Trustee to pay the sum now assigned, I appoint Assignee as my attorney-in-fact, with full power of substitution and revocation, in his own name, to ask, demand, sue for, collect, receive, appoint, and compel Trustee to account to him and give acquittal for the annual income assigned to him by this instrument. Witness my signature on this __________________________________________ (date). ____________________________________Signature of Beneficiary____________________________________ Printed Name of Beneficiary (Acknowledgments form may vary by state) STATE OF ____________________________________________ 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 _______________________________ ___________________________________ (Name of Beneficiary), who acknowledged that he executed the above and foregoing instrument. ____________________________________ NOTARY PUBLIC My Commission expires:______________________