Fill and Sign the Revocable Contingent Assignment of Death Benefits under a Form

Assignment of Life Insurance Proceeds to Funeral Director Assignment made on the ______________ (date), from ___________________ (Name of Assignor) of ___________________________________________________ __________________ (street address, city, state, zip code), referred to herein as Assignor, to __________________ (Name of Assignee), a corporation organized and existing under the laws of the state of _______________, with its principal office located at ____________________________________________________________________ ________ (street address, city, state, zip code) , referred to herein as Assignee.For and in consideration of the services rendered by Assignee associated with the burial of ____________________ (Name of Decedent) , and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, Assignor does hereby assign to Assignee $____________ of the proceeds of Life Insurance Policy No. ___________ issued by __________________________ (Name of Insurance Company), that may be or is due me from that Insurance Company as Beneficiary of the Policy.I direct ________________________ (Name of Insurance Company) to pay to _____________________ (Name of Assignee) $_____________ out of the proceeds that may be due me as Beneficiary under that Policy upon presentation and release by ___________________ (Name of Assignee) of this assignment and a certified receipted funeral expense statement of the burial of ______________________ (Name of Decedent) . The payment of the $_______________ by _______________________ (Name of Insurance Company), upon the presentation of such documents, shall be a release for that amount of those proceeds otherwise due to me.I have caused this Assignment to be executed at _________________________ _______________________ (place of execution) on ___________________ (date). ________________________(Printed Name of Assignor)________________________ (Signature of Assignor) (Acknowledgment 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 _______________ (date), within my jurisdiction, the within- named ______________________ (Name of Assignor), who acknowledged that she executed the above and foregoing instrument. ________________________________NOTARY PUBLICMy Commission Expires:____________________