D ESIGNATION OF PERSON TO RECEIVE CHECKS UPON THE

In the event of my death, I hereby designate the following person to receive from my employer all warrants or checks that would have been payable to me if I had survived, pursuant to California Government Code Section 53245.

Name of my Designee      

Address of Designee      

City       State       Zip      

Telephone number       Relationship      

If this person should predecease me, I hereby designate the following person as a secondary designee.

Name of Secondary Designee      

Address of Secondary Designee      

City       State       Zip      

Telephone number       Relationship      

Notwithstanding any other provision of law , my employer shall, upon my death, deliver to the person named above any and all warrants or checks which would have been payable to me, and that person may negotiate them as if the payee.

This designation revokes and replaces any other designation which I have previously signed, and shall remain in effect until I revoke or replace it.

Name of Employee      

(Please Print)

Social Security Number    –  –    

Signature ________________________________ Date      

Note to employee: You may change this designation at any time.