I, , hereby designate as my beneficiary to receive, upon my death, the benefits to which I am entitled to pursuant to the East Buchanan Community School District’s Retirement Program.
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Signature Date
STATE OF IOWA )
) ss:
BUCHANAN COUNTY )
On this day of 20 , before me, the undersigned, a Notary Public for the State of Iowa, personally appeared , to me personally known to be the identical person named in and who executed the foregoing instrument and acknowledged that they executed the same as their voluntary act and deed.
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NOTARY PUBLIC, STATE OF IOWA