UNITED STATES DEPARTMENT OF THE ARMY

THE PENTAGON, ARLINGTON COUNTY, VIRGINIA, U.S

369TH SUSTAINMENT BRIGADE

HARLEM, MANHATTAN, NEW YORK

BENEFICIARY APPLICATION FORM

PLEASE PROVIDE THE INFORMATION REQUESTED BELOW FOR FAMILY MEMBERS WHO MAY BE CONTACTED
IN THE EVENT OF YOUR DEATH OR IN ANY CASE OF EMERGENCY

DESIGNATED BENEFICIARY INFORMATION

FULL NAME (Last, First, Middle Initial) SSN RELATIONSHIP

ADDRESS (Street, Apartment Number, City, State and ZIP DATE OF BIRTH (DD/MM/YYYY)
Code)

OCCUPATION

BENEFICIARY SIGNATURE DATE SIGNED

I ______________________________________ of ________________________________________________
do hereby declare that all the details provided above are true and correct about me, and I voluntarily stand in as
beneficiary of officer_____________________________________________.

FOR OFFICIAL USE ONLY

With the confirmation of the above information’s is about you. I hereby declare under the military act that all
earnings, benefits, bonuses and award for ___________________________________________ be sent to you
in an event of death or any other emergency.

LT. COL. MICHAEL BEDRYKE APPLICANT

COMMANDER 369TH
SUSTAINMENT BRIGADE
HARLEM, MANHATTAN, NEW
YORK

OFFICE OF THE UNITED STATE

SECRETARY OF THE ARMY