IRREVOCABLE ASSIGNMENT AND POWER OF …

1 IRREVOCABLE ASSIGNMENT AND POWER OF ATTORNEY. FOR VALUE RECEIVED, I(WE), THE UNDERSIGNED BENEFICIARY(IES) UNDER THE INSURANCE policy (IES), OR death BENEFIT. CERTIFICATE(S) (COLLECTIVELY, THE policy (IES) ) REFERRED TO BELOW, OR BEING THE PERSON EQUITABLY ENTITLED TO THE. benefits THEREUNDER ISSUED BY_____ (NAME OF INSURANCE COMPANY). policy NUMBER(S): _____ _____ _____ _____. ( policy NUMBER) ( policy NUMBER) ( policy NUMBER) ( policy NUMBER). ON THE LIFE OF _____ (THE DECEASED ) DO HEREBY IRREVOCABLY ASSIGN, SET. OVER AND TRANSFER UNTO _____ (THE FUNERAL HOME ) ITS SUCCESSORS AND. ASSIGNS, THE SUM OF _____ ($_____). (WRITE IN THE AMOUNT BEING APPLIED IN DOLLARS AND CENTS) (DOLLARS). TO BE PAID FROM THE benefits OF THE ABOVE-MENTIONED policy (IES), PLUS STATUTORY INTEREST FROM THE DECEASED'S DATE OF death , THE. CONSIDERATION FOR THE ASSIGNMENT OF THIS AMOUNT BEING (1) FUNERAL SERVICES RENDERED IN THE BURIAL OF SAID DECEASED BY THE.

2 FUNERAL HOME, WHICH SERVICES HAVE BEEN ACCEPTED BY US AND/OR (2) FUTURE PROVISION OF THE ABOVE-MENTIONED SERVICES. IN THE. EVENT THAT THE INSURANCE COMPANY SETTLEMENT AMOUNT ON THE policy (IES) IS LESS THAN THE AMOUNT OF THIS ASSIGNMENT , I(WE) AGREE. TO PAY THE DEFICIT TO THE FUNERAL HOME AND/OR ITS ASSIGNEE UPON REQUEST TO PAY. IF ANY PAYMENTS OF THE SAID PROCEEDS ARE. ERRONEOUSLY MADE TO ME (US) UNDER THE PROVISIONS OF THE ABOVE DESCRIBED policy (IES), SUBSEQUENT TO THE EXECUTION OF THIS. ASSIGNMENT , THEN I(WE) AGREE TO HOLD THE SAID PROCEEDS IN TRUST FOR THE USE OF THE FUNERAL HOME AND ITS ASSIGNEE, THEIR. SUCCESSORS AND ASSIGNS. THE UNDERSIGNED HEREBY APPOINTS THE FUNERAL HOME, AND ITS SUCCESSORS AND ASSIGNS, AS OUR ATTORNEY-IN-FACT, WHICH POWER OF. ATTORNEY IS IRREVOCABLE AND IS COUPLED WITH AN INTEREST TO ACT FOR US WITH FULL POWER TO MAKE COLLECTION OF, COMPROMISE, SETTLE.

3 AND TO ENDORSE OR RECEIPT IN MY(OUR) NAME(S), OR OTHERWISE, ANY CHECK, DRAFT, RECEIPT OR RELEASE FOR THE PROCEEDS OF SAID. policy (IES) AS FULLY TO ALL INTENTS AND PURPOSES AS WE OURSELVES COULD DO, HEREBY RATIFYING AND CONFIRMING ALL THAT OUR SAID. ATTORNEY MAY DO OR CAUSE TO BE DONE BY VIRTUE HEREOF. THE UNDERSIGNED ALSO AUTHORIZES AND DIRECTS ANY ORGANIZATION, AGENCY, ENTITY, OR PERSON TO GIVE AND RELEASE ANY AND ALL INFORMATION REGARDING THE policy (IES) TO THE FUNERAL HOME, IT'S SUCCESSORS AND. ASSIGNS, OR ANYONE ACTING ON THEIR BEHALF. THE UNDERSIGNED GRANT TO THE FUNERAL HOME, AND ANY OF IT'S SUCCESSORS AND ASSIGNS, PERMISSION TO OBTAIN ALL PRIVACY ACT AND FREEDOM OF INFORMATION ACT INFORMATION REQUESTED BY THEM TO PROCESS ALL INSURANCE. CLAIMS HEREUNDER. THE UNDERSIGNED CERTIFY THAT THEY ARE EACH OVER THE AGE OF EIGHTEEN (18) YEARS AND NOT UNDER A LEGAL. INCAPACITY.

4 THIS ASSIGNMENT WILL BE INTERPRETED UNDER VIRGINIA LAW. THE ASSIGNEE(S) SHALL BE ENTITLED TO COLLECT THEIR COSTS. (INCLUDING REASONABLE ATTORNEY FEES) AND INTEREST (@ THE GREATER OF 18% PER ANNUM OR THE MAXIMUM ALLOWABLE BY APPLICABLE. LAWS) IN ENFORCING THIS ASSIGNMENT . IN WITNESS WHEREOF, I(WE) HAVE SET OUR HAND(S) AND SEAL(S) AT _____. (CITY AND STATE). THIS _____ DAY OF _____(MONTH), _____ (YEAR): _____. ST. (SIGNATURE OF 1 BENEFICIARY). _____. STATE/DISTRICT OF _____ (SIGNATURE OF 2. ND. BENEFICIARY). CITY/COUNTY OF _____. I, _____, A NOTARY PUBLIC IN AND FOR THE CITY/COUNTY AND STATE/DISTRICT AFORESAID, DO. HEREBY CERTIFY THAT _____ PERSONALLY APPEARED BEFORE ME THIS _____ DAY OF. _____(MONTH), _____ (YEAR), AND, AFTER HAVING BEEN DULY SWORN, ACKNOWLEDGED AND AFFIRMED THE FOREGOING. ASSIGNMENT . _____ MY COMMISSION EXPIRES: _____. (NOTARY PUBLIC). ---------------------------------------- ---------------------------------------- ---------------------------------------- ---------------------------------------- ------------------ IRREVOCABLE ASSIGNMENT AND POWER OF ATTORNEY TO.

5 BETA CAPITAL CORP. FOR VALUE RECEIVED, THE UNDERSIGNED DOES HEREBY IRREVOCABLY ASSIGN, TRANSFER, CONVEY AND SET OVER UNTO BETA CAPITAL CORP., AND THEIR. RESPECTIVE SUCCESSORS AND ASSIGNS (COLLECTIVELY, ASSIGNEES ), ALL OF IT'S RIGHTS, TITLE, INTEREST AND CLAIMS IN AND TO THE WITHIN ASSIGNMENT , AND. ( ) . DIRECT THAT PAYMENT ON THE policy IES BE MADE TO BETA CAPITAL CORP AT THE ADDRESS BELOW. THE UNDERSIGNED APPOINTS. BETA CAPITAL CORP., AND THEIR RESPECTIVE SUCCESSORS AND ASSIGNS, AS IT'S ATTORNEYS-IN-FACT, WHICH POWER OF ATTORNEY IS IRREVOCABLE AND COUPLED. WITH AN INTEREST, TO ACT FOR IT'S WITH FULL POWER TO MAKE COLLECTION OF, COMPROMISE, SETTLE, AND TO ENDORSE OR RECEIVE IN THE NAME OF THE. UNDERSIGNED, ANY CHECK, DRAFT, RECEIPT, OR RELEASE FOR THE PROCEEDS OF THE policy (IES), AS FULLY TO ALL INTENTS AND PURPOSES AS THE UNDERSIGNED, HEREBY RATIFYING, CONFIRMING AND APPROVING ANYTHING THAT SAID ATTORNEYS MAY DO OR CAUSE TO BE DONE BY VIRTUE HEREOF.

6 THIS POWER OF ATTORNEY. SHALL BE IRREVOCABLE , AND COUPLED WITH AN INTEREST. IN THE EVENT THAT ANY PAYMENTS OF PROCEEDS ARE MADE BY THE INSURANCE COMPANY, OR ITS. AGENT, TO THE UNDERSIGNED, ERRONEOUSLY, SUBSEQUENT TO THE EXECUTION OF THIS REASSIGNMENT TO ASSIGNEES, THEN THE UNDERSIGNED AGREES TO HOLD. THE PROCEEDS IN TRUST AND TO IMMEDIATELY PAY THE PROCEEDS TO ASSIGNEES AS HEREIN PROVIDED. THE UNDERSIGNED CERTIFIES THAT THE PERSON(S) SO. NAMED ABOVE IS/ARE THE CORRECT INSURANCE CONTRACT BENEFICIARY(IES), AND THAT THE BENEFICIARY(IES) IS/ARE EIGHTEEN (18) YEARS OF AGE OR OLDER AND. ARE NOT UNDER A LEGAL INCAPACITY. THIS ASSIGNMENT WILL BE INTERPRETED UNDER VIRGINIA LAW. THE ASSIGNEE(S) SHALL BE ENTITLED TO COLLECT ITS COSTS. (INCLUDING REASONABLE ATTORNEY FEES) AND INTEREST (@ THE GREATER OF 18% PER ANNUM OR THE MAXIMUM RATE ALLOWABLE BY APPLICABLE LAWS ) IN. ENFORCING THIS ASSIGNMENT .

7 _____ (Name of funeral home). STATE/DISTRICT OF _____. BY: _____. CITY/COUNTY OF _____ AUTHORIZED SIGNATORY FOR FUNERAL HOME. I, _____ , A NOTARY PUBLIC IN AND FOR THE CITY/COUNTY AND STATE/DISTRICT AFORESAID, DO HEREBY CERTIFY THAT _____, PERSONALLY APPEARED BEFORE ME THIS _____ DAY. OF _____ (MONTH), _____ (YEAR), IN PERSON, AND AFTER HAVING BEEN DULY SWORN, ACKNOWLEDGED AND AFFIRMED THE. FOREGOING REASSIGNMENT ON BEHALF OF THE FUNERAL HOME. _____ MY COMMISSION EXPIRES: _____. (NOTARY PUBLIC). BETA CAPITAL CORP. 4007 SEABOARD COURT, SUITE 1, PORTSMOUTH, VA 23701. TELEPHONE: (757) 488-6960 TOLL FREE: (800) 430-7935 FAX: (877) 375-9118