Ds 5002 Form – Fill Out and Use This PDF

A.ORDER OF PRECEDENCE (3 FAM 673.8-5)

(Section 815 (f) of the Foreign Service Act of 1980, as amended)

If there is no designated beneficiary living, any lump-sum benefit that becomes payable after the death of a participant or a former participant will be payable to the first person or persons listed below who are alive on the date the title to the payment arises:

1.To the surviving wife or husband of the participant.

2.If there is no surviving wife or husband, to the child or children of such participant and descendants of deceased children by representation.

3.If none of the above, to the parents of such participant or the survivor of them.

4.If none of the above, to the duly appointed executor or administrator of the estate of such participant.

5.If none of the above, to other next of kin of such participant as may be determined by the Secretary in his/her judgement to be legally entitled thereto.

It is not necessary for any participant or former participant to designate a beneficiary unless he/she wishes to name some person or persons not included above, or in a different order.

B.PURPOSE OF DESIGNATING A BENEFICIARY

A designation of beneficiary is for lump-sum benefit purposes only, and does not affect the right of any person who qualifies to receive survivor annuity benefits. Such benefits are payable either by operations of law or as a result of an election made by a retiring participant.

C.INSTRUCTIONS

1.The examples printed may be helpful to you.

2.Type or print all entries except signatures.

3.This form must be completed and mailed to the appropriate Personnel Office. The designation must be received prior to the death of the participant or former participant to be valid.

4.Cancellation of a prior designation may be effected without naming a new beneficiary by completing out a new DS-5002 and inserting in the space provided for name of beneficiary the words, "Cancel Prior Designation."

5.This form is not intended as a will, and miscellaneous provisions such as payment of just debts, payment of monthly installment plan, etc., will not be recognized.

6.A designation free of erasures or alterations should be filed in order to avoid a possible contest after death.

7.A copy will be returned to you as evidence that the original has been received and filed. When you receive the duplicate, file it with your important papers.

D. REGULATIONS (3 FAM 673.8-6)

1.The designation of beneficiary shall be in writing, signed and witnessed, and received in the Department or Agency prior to the death of the participant.

2.No change or cancellation of beneficiary in a last will or testament, or in any other document not witnessed and filed as required by these regulations, shall require the Department or Agency to pay any alleged beneficiary other than the beneficiary designated by the document witnessed and filed in accordance with these regulations. Payment of the beneficiary so designated shall relieve the Department or Agency of liability to any other claimant.

3.A witness to a designation of beneficiary is ineligible to receive payment as a beneficiary.

4.A change of beneficiary may be made at any time and without the knowledge or consent of the previous beneficiary unless the participant has obligated himself/ herself under appropriate State law to do so. If the Department or Agency is not notified of any such obligation before payment is made, payment to the beneficiary designated in accordance with the Department's or Agency's regulations, discharge the Department

or Agency of any further responsibility.

Title 5, U. S. Code, authorizes solicitation of this information. Your designation of beneficiary will be used to determine who will receive a lump-sum benefit in the event of your death.

This information may be shared with national, State, local or other charitable, Social Security Administrative or law enforcement agencies to determine and issue benefits under their programs or, in the latter case, when they are investigating a violation or potential violation of the civil or criminal law.

Executive Order 9397 (November 22, 1943) authorizes use of the Social Security Number to distinguish between you and people with similar names. Furnishing your Social Security Number, as well as the other date, is voluntary, but failure to do so may result in your agency's inability to determine who is eligible to receive a lump-sum benefit in the event of your death.

	Type or print the first name, middle initial, and last	Type or pint the address of each beneficiary.	Relationship	Share to be Paid to
	name of each beneficiary.			Each Beneficiary.
	SARAH M. JONES	22 Elm Street, Lima, Ohio	Sister	All

How to Designate More than One Beneficiary

	Type or print the first name, middle initial, and last	Type or print the address of each beneficiary.	Relationship	Share to be Paid to
	name of each beneficiary.			Each Beneficiary.
	MARY A. SMITH	4902 Oak Street, Jason, North Dakota	Aunt	One-half
	ANNA D. BROWN	50 Duke Street, Jason, North Dakota	Cousin	One-fourth
	HENRY G. BROWN	50 Duke Street, Jason, North Dakota	None	One-fourth

Do not write name as S.M. Jones or as Mrs. George

L. Jones.

Be sure the shares to be paid to the beneficiaries add up to 100%.

How to Cancel a Designation of Beneficiary

	Type or print the first name, middle initial, and last	Type or print the address of each beneficiary.	Relationship	Share to be Paid to
	name of each beneficiary.			Each Beneficiary.

Cancel Prior Designation

You may want to cancel a beneficiary you have named

if your circumstances change and you want the benefit payable to your wife, husband, children, or parents in that order.

1.Name (Last, First, MI.)

2. Date of Birth (mm-dd-yyyy)

3. Social Security Number

4. Date of this Designation (mm-dd-yyyy)

5. Post of Assignment (City and Country)

6. Employing Department or Agency

7. If Retired, Date of Retirement (mm-dd-yyyy)

Type or print the first name, middle initial,

and last name of each beneficiary.

Type or print the address of each beneficiary.

Relationship

Share to be Paid to Each Beneficiary