NOMINATION OF BENEFICIARY FORM

Name of Staff: Agus Dianto__________________________________________________________________

Title/Designation: LISTRA LIGOT Research Assistant for #PahlawanGambut______________________________

Division/Unit: Sustainable Household Theme/Peat-Impacts Project__________________________________

Personal Number: 082352466667________________________________________________________________

I hereby nominate the following person(s) as the official beneficiary (ies) of all my terminal dues in the event of my
death:

1. Name of beneficiary: Sufiyeh_______________________________ Percentage: 100%____

Address: Dusun Karya Bakti RT 001/ RW 001 Desa Sepakat Baru Kecamatan Kubu Kabupaten Kubu Raya
_______________________________________________________________________

National ID Card/Passport No: 6112064607740001____________________________________________

2. Name of beneficiary: _____________________________________ Percentage: ______________

Address: _______________________________________________________________________

National ID Card/Passport No: ______________________________________________________

3. Name of beneficiary: _____________________________________ Percentage: ______________

Address: _______________________________________________________________________

National ID Card/Passport No: ______________________________________________________

4. Name of beneficiary: _____________________________________ Percentage: ______________

Address: _______________________________________________________________________

National ID Card/Passport No: ______________________________________________________

* In the case of (s): Name of Trustee: AGUS DIANTO

Address: Dusun Karya Bakti RT 001/ RW 001 Desa Sepakat Baru Kecamatan Kubu Kabupaten Kubu Raya

National ID Card/Passport No: 6112061208940001____________________________________________

Signature of Staff: ___________ ___ _____________________________ Date: __March 30, 202____

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Note:
Change of the beneficiary must be done through the nomination of beneficiary form where the most current dated form
supersedes all others. If you have nominated more that one beneficiary, clearly indicate the percentage of distribution of the dues
to each beneficiary e.g Beneficiary one: 60%; Beneficiary two: 40% etc. Of the beneficiary is one then all dues (100%) will be
paid to the sole beneficiary. If you have nominated a minor(s) as your beneficiary, please ensure to also nominate an adult as the
trustee for the minor(s) and provide the details of the Trustee above.

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Fax: 254 7224001 or via USA 1 650 833 6646 | Email:icraf@cgiar.org | http: www.worldagroforestrycentre.org