DEPARTMENT OF Shuster Hall, Room 230 Phone: 718-960-8181 HUMAN RESOURCES 250 Bedford Park Blvd West Fax: 718-960-1191 Bronx, NY 10468 www.lehman.edu Unused Annual Leave Benefit-Designation of Beneficiary . Teaching and Non Teaching Instructional Full Time Staff . (text) (text) Name (Print) Social Security Number (text) Title In accordance with Item No. 17 of the Board of Higher Education minutes of Proceedings dated August 1, 1977, the payment of accrued annual leave as provided for therein is t be paid to the following beneficiary or beneficiaries or to my estate as indicated below in the following manner. (Fill in 1 and 2 if you desire to name beneficiaries other than your estate). 1.PRIMARY BENEFICIARIES RELATIONSHIP % OF BENEFIT (include addresses) (text) (text) (text) (text) (text) (text) (text) (text) (text) 2. CONTINGENT BENEFICIARIES RELATIONSHIP % OF BENEFIT (include addresses) (text) (text) (text) (text) (text) (text) (text) (text) (text) 3. It is my understanding that by not designating a beneficiary, this benefit will be paid to my estate. ALL PREVIOUS DESIGNATED BENEFICIARIES FOR CASH PAYMENT OF ACCRUED ANNUAL LEAVE ARE HEREBY CANCELLED AND IT IS DIRECTED THAT PAYMENT BE MADE UPON MY DEATH AS SPECIFIED ABOVE. Signature of Employee (Do not print) Address of Employee (text) (text) (text) Signed at (City, State) Date signed