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-0020 www.rsa-al.gov Name First Middle/Maiden Last Address Street or P. O. Box City State Social Security Number ( Zip Code Phone Number ) Check if Beneficiary information is continued on the back of this form. DESIGNATION OF PRIMARY BENEFICIARY(IES) I hereby designate the following person(s) as my primary beneficiary(ies) to receive any benefit that may become due at or after my death according to the terms of the Plan. Name: Relationship: Date of Birth: mm/dd/yyyy Address: S.

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