Gwinnett Widows Fund Enrollment

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Date:

Certificate No.

Name:

Telephone:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Lodge#:

Recipients:

Put as many beneficiaries as you would like. Also explain if they should be paid sequentially (so #1 if alive, will get all. If not, then #2, and so on) or if they should be paid according to a percentage. Please enter all data to explain how you would want the benefit paid out.