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Change of Status or Termination Form

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Applicant

Name (Previous if changed):(Required)

First Middle Last

Jurisdiction/Agency(Required)

Employee ID #(Required)

Email(Required)

Name and/or Address Update

Select

Name Change

Name(Required)

First Middle Last

Select

Address Change

Address(Required)

Street Address City State ZIP Code

Jurisdiction Update

Select Jurisdiction

Jurisdiction Update

New Jurisdiction(Required)

New Employee ID #(Required)

Date of Termination with Previous Agency(Required)

Date of Employment with New Agency(Required)

Days Difference

This 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 Update

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)

Relationship(Required)

Percent(Required)

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Beneficiary 1 Age

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Beneficiary 1 Value

Note: Beneficiaries cannot be a juvenile. Find out why here.

Address(Required)

Street Address City State ZIP Code

2nd Beneficiary

Add 2nd Beneficiary

Name(Required)

First Middle Last

Phone Number(Required)

Date of Birth(Required)

Relationship(Required)

Percent(Required)

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Beneficiary 2 Age

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Beneficiary 2 Value

Note: Beneficiaries cannot be a juvenile. Find out why here.

Address(Required)

Street Address City 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)

Relationship(Required)

Percent(Required)

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Beneficiary 3 Age

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Beneficiary 3 Value

Note: Beneficiaries cannot be a juvenile. Find out why here.

Address(Required)

Street Address City State ZIP Code

2nd Beneficiary

Add 2nd Beneficiary

Name(Required)

First Middle Last

Phone Number(Required)

Date of Birth(Required)

Relationship(Required)

Percent(Required)

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Beneficiary 4 Age

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Beneficiary 4 Value

Note: Beneficiaries cannot be a juvenile. Find out why here.

Address(Required)

Street Address City State ZIP Code

Termination

Date Last Employed(Required)

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)

Signature(Required)

Today's Date: 08/15/2026

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Contingent Beneficiary Percent VAL

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Beneficiary Percent VAL

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Beneficiary Percent

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Contingent Beneficiary Percent

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Juvenile Notification Value

Note: Beneficiaries cannot be a juvenile.

Beneficiary Percent must total to 100...Please adjust

Contingent Beneficiary Percent must total to 100...Please adjust

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About Us
Benefits
Resources
Contact Us
Share your Story

info@lawenforcementfund.org

The Law Enforcement Benevolent Fund
4094 Majestic Lane, #378
Fairfax, VA 22033

ABOUT US
BENEFITS
RESOURCES
CONTACT US
SHARE YOUR STORY

info@lawenforcementfund.org

The Law Enforcement Benevolent Fund
4094 Majestic Lane, #378
Fairfax, VA 22033