Change of Status or Termination Form This field is hidden when viewing the formApplicantName (Previous if changed):(Required) First Middle Last Jurisdiction/Agency(Required)Jurisdiction/AgencyAlexandria PoliceAlexandria SheriffArlington PoliceArlington SheriffFairfax City PoliceFairfax County PoliceFairfax County SheriffFairfax DPSCFalls Church PoliceFalls Church SheriffFauquier County SheriffFredericksburg PoliceFredericksburg SheriffHerndon PoliceLoudoun County SheriffManassas City PoliceManassas Park PolicePrince William PolicePrince William SheriffStafford County SheriffVienna PoliceWarrenton PoliceEmployee ID #(Required)Email(Required) Name and/or Address UpdateSelectSelect Name Change Name(Required) First Middle Last Select Address Change Address(Required) Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Jurisdiction UpdateSelect Jurisdiction Jurisdiction Update New Jurisdiction(Required)Alexandria PoliceAlexandria SheriffArlington PoliceArlington SheriffFairfax City PoliceFairfax County PoliceFairfax County SheriffFairfax DPSCFalls Church PoliceFalls Church SheriffFauquier County SheriffFredericksburg PoliceFredericksburg SheriffHerndon PoliceLoudoun County SheriffManassas City PoliceManassas Park PolicePrince William PolicePrince William SheriffStafford County SheriffVienna PoliceWarrenton PoliceNew Employee ID #(Required)Date of Termination with Previous Agency(Required) MM slash DD slash YYYY Date of Employment with New Agency(Required) MM slash DD slash YYYY Days DifferenceThis section may be used if transferring from one member agency to another with a break of 30 days or less in employment. If the break is more than 30 days, a new application must be submitted.Beneficiary UpdateBeneficiary Change Beneficiary Change(If any changes to your beneficiaries are made you must list all primary and contingent beneficiaries on this form) I hereby designate the following person(s) as my beneficiary(ies) for the LEBF Primary Beneficiary(ies): in equal shares or as indicated below:Primary Beneficiary(ies)Name(Required) First Middle Last Phone Number(Required)Date of Birth(Required) MM slash DD slash YYYY Relationship(Required)RelationshipSpouseParentChildSiblingGrandchildCousinFriendOtherPercent(Required)Percent100999897969594939291908988878685848382818079787776757473727170696867666564636261605958575655545352515049484746454443424140393837363534333231302928272625242322212019181716151413121110987654321This field is hidden when viewing the formBeneficiary 1 AgeThis field is hidden when viewing the formBeneficiary 1 ValueNote: Beneficiaries cannot be a juvenile. Find out why here. Address(Required) Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 2nd Beneficiary Add 2nd Beneficiary Name(Required) First Middle Last Phone Number(Required)Date of Birth(Required) MM slash DD slash YYYY Relationship(Required)RelationshipSpouseParentChildSiblingGrandchildCousinFriendOtherPercent(Required)Percent100999897969594939291908988878685848382818079787776757473727170696867666564636261605958575655545352515049484746454443424140393837363534333231302928272625242322212019181716151413121110987654321This field is hidden when viewing the formBeneficiary 2 AgeThis field is hidden when viewing the formBeneficiary 2 ValueNote: Beneficiaries cannot be a juvenile. Find out why here. Address(Required) Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contingent Beneficiary(ies) checkbox Add Contingent Beneficiary(ies) Contingent Beneficiary(ies)As shall be living, and if no such Primary Beneficiary is then living, Contingent Beneficiary(ies): In equal shares or as designated below: Name(Required) First Middle Last Phone Number(Required)Date of Birth(Required) MM slash DD slash YYYY Relationship(Required)RelationshipSpouseParentChildSiblingGrandchildCousinFriendOtherPercent(Required)Percent100999897969594939291908988878685848382818079787776757473727170696867666564636261605958575655545352515049484746454443424140393837363534333231302928272625242322212019181716151413121110987654321This field is hidden when viewing the formBeneficiary 3 AgeThis field is hidden when viewing the formBeneficiary 3 ValueNote: Beneficiaries cannot be a juvenile. Find out why here. Address(Required) Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 2nd Beneficiary Add 2nd Beneficiary Name(Required) First Middle Last Phone Number(Required)Date of Birth(Required) MM slash DD slash YYYY Relationship(Required)RelationshipSpouseParentChildSiblingGrandchildCousinFriendOtherPercent(Required)Percent100999897969594939291908988878685848382818079787776757473727170696867666564636261605958575655545352515049484746454443424140393837363534333231302928272625242322212019181716151413121110987654321This field is hidden when viewing the formBeneficiary 4 AgeThis field is hidden when viewing the formBeneficiary 4 ValueNote: Beneficiaries cannot be a juvenile. Find out why here. Address(Required) Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code TerminationTermination Termination Date Last Employed(Required) MM slash DD slash YYYY Termination reason:(Required) Retired Resigned Other Other termination reason:(Required)Member terminated without completing form, form completed by agency Director (agency Director signature required below) Member terminated without completing form, form completed by agency Director (agency Director signature required below)Signature(Required)Today's Date: 12/21/2024This field is hidden when viewing the formContingent Beneficiary Percent VALThis field is hidden when viewing the formBeneficiary Percent VALThis field is hidden when viewing the formBeneficiary PercentThis field is hidden when viewing the formContingent Beneficiary PercentThis field is hidden when viewing the formJuvenile Notification ValueNote: Beneficiaries cannot be a juvenile.Beneficiary Percent must total to 100...Please adjustContingent Beneficiary Percent must total to 100...Please adjustCAPTCHACommentsThis field is for validation purposes and should be left unchanged. 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