Beneficiary Affidavit

Introduction

I, [Your Name], of legal age, residing at [Your Address], City of [Your City], County of [Your County], State of [Your State], do hereby make this Affidavit under oath and affirmation, pursuant to the laws of [Your State], to support my claim for life insurance benefits.

Statement of Facts

1. I am the designated beneficiary of the life insurance policy, policy number [Policy Number], issued by [Insurance Company Name], insuring the life of the deceased, [Name of Insured].

2. I certify that [Name of Insured] passed away on [Date of Death].

3. I confirm that I am the [Relationship to the Deceased] of the deceased, [Name of Insured].

4. I understand that by signing this affidavit, I am attesting to the truthfulness and accuracy of the information provided herein.

5. I hereby authorize and request [Insurance Company Name] to release the proceeds of the above-mentioned life insurance policy to me as the designated beneficiary.

6. I acknowledge that any false statements made in this affidavit may result in legal consequences.

Sworn Oath

I solemnly swear (or affirm) under penalty of perjury that the foregoing statements are true and correct to the best of my knowledge, information, and belief.

Signature

This affidavit is executed on this day [Date], at [Location].

[Your Name]

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I, the undersigned, hereby declare that the above-named affiant signed or acknowledged this Affidavit in my presence and that I believe the affiant to be of sound mind and under no constraint or undue influence.

[Witness' Name]

[Date]

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State of [Your State]

County of [Your County]

On this [Date], before me, the undersigned authority, personally appeared [Your Name], known to me to be the person described in and who executed the foregoing instrument, and acknowledged that he/she/they executed the same as his/her/their free and voluntary act and deed for the uses and purposes therein set forth.

Given under my hand and official seal, this [Date].

Notary Public, [Your State]

My Commission Expires: [Date]

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