Form Exchange Form 1700 Exchange Form 1700 Beneficiary Designation

OMB NO. 0702-0139
OMB approval expires
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Army and Air Force Exchange Service (AAFES)
BENEFICIARY DESIGNATION
AGENCY DISCLOSURE NOTICE

PRIVACY ACT STATEMENT

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The public reporting burden for this collection of information, 0702-0139, is estimated to average 20 minutes
per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington
Headquarters Services, at [email protected]. Respondents should
be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to
comply with a collection of information if it does not display a currently valid OMB control number.

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AUTHORITY: 10 U.S.C. 7013, Secretary of the Army; 10 U.S.C. 9013, Secretary of the Air Force; 42 U.S.C.
659, Consent by United States to Income Withholding, Garnishment, and Similar Proceedings for Enforcement
of Child Support and Alimony Obligations; 31 CFR 285.11, Administrative Wage Garnishment; DoD
Directive 7000.14-R, DoD Financial Management Regulation; DoD Instruction 1400.25, Volume 1408, DoD
Civilian Personnel Management System: Insurance and Annuities for Nonappropriated Fund (NAF)
Employees; Army Regulation 215-8/AFI 34-211(I), Army and Air Force Exchange Service Operations; and
E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSES: To provide adequate information for Insurance Providers under contract
with AAFES for specifics on life insurance beneficiaries.

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ROUTINE USES: Records may be disclosed outside of DoD pursuant to Title 5 U.S.C. §552a(b)(3)
regarding DoD “Blanket Routine Uses” published at
http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx. Information may be released to
former spouses and/or survivors, to Federal, State, or Local Child Support agencies for purposes of
assisting in discharge of their responsibilities under Federal and State law.

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DISCLOSURE: Voluntary, however, failure to provide the requested information may result in the denial of
payments to your elected beneficiaries.

A copy of the Privacy Impact Assessment (PIA) for the collection of information may be located at https://www.aafes.com/aboutexchange/public-affairs/FOIA/assessments.htm

SYSTEM OF RECORD NOTICE (SORN): AAFES 0703.07 "Employee Pay System Records" may be viewed at
http://dpclddefense.gov/Privacy/SORNsIndex/?Page=9

EXCHANGE FORM 1700-012 (DRAFT)

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Army and Air Force Exchange Service (AAFES)
BENEFICIARY DESIGNATION
INSTRUCTIONS
A copy of this completed form will be maintained within your AAFES Official Personnel File. Please be sure to keep a copy of this
form for your records.

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IMPORTANT:  If you received credit for regular full‐time service as a civilian employee under the retirement plan of 
another DoD NAFI and were subsequently hired by AAFES within 90 days after termination, then your service credit 
under the prior NAFI Plan will count as Credited Civilian Service under the AAFES Plan in the same manner as for AAFES 
employees. YOU MUST PROVIDE AAFES HQ BENEFITS TREASURY A COPY OF THE ACTION OF PRIOR NAFI RETIREMENT. 
The following instructions are provided as a guidance for completing the following form. 

1. Please read the Agency Disclosure Notice and Privacy Act Statement on the previous pages prior to completing
this form.   If you have any questions please contact AAFES HQ Treasury Benefits at 800‐519‐3381.

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2. SECTION I:  Please provide all personal information at the top of the form where requested.  Your Social Security
Number is required to locate all pertinent information for updating your records.
3. SECTION II:  Complete all areas in this section ONLY if you wish for the SAME beneficiaries to share EQUALLY for
all programs.  The beneficiary’s SSN is required for payment and tax purposes.   Your choice for primary
beneficiary should be listed first.  In the event this beneficiary is not living at the time of your death, a secondary
beneficiary should be listed on the second line.  For each beneficiary you must provide full name, SSN, address,
date of birth and relationship.  Should you require more room to provide your choice of beneficiaries, please
provide a separate page with all the requested information.  Each additional page must be signed by you,
witnessed, and dated.

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4. SECTION III:  Complete all areas in this section ONLY if you wish to choose DIFFERENT beneficiaries for each
program.  The beneficiary’s SSN is required for payment and tax purposes.   Your choice for primary beneficiary
should be listed first.  In the event this beneficiary is not living at the time of your death, a secondary beneficiary
should be listed on the second line.  This section is divided into sub‐sections for each benefit program.  For each
beneficiary in each sub‐section, you must provide full name, SSN, address, date of birth and relationship.  Should
you require more room to provide your choice of beneficiaries, please provide a separate page with all the
requested information.  Each additional page must be signed by you, witnessed, and dated.

5. SECTION III – PART F – 401(k):  This section is required ONLY if you wish to provide a specific percentage of the
available benefit to each beneficiary.  Otherwise, beneficiaries will share equally in available benefits.

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6. When completed and signed in front of a witness, gather any required attachments and make a copy of all
documents for your records.  Then mail the form and any attachments to AAFES HQ Treasury Benefits, P.O. 
Box 650428, Dallas TX 75265‐0428.  AAFES HQ Treasury Benefits will update your beneficiary records.

7. Please read the next page providing you important considerations when choosing beneficiaries and providing
information on this form.

The information you provide on this form and any attachments, if signed and witnessed, will replace any previous 
forms where you designated beneficiaries.  If any page is not signed or if any page is not witnessed, it is not valid, and 
all previous forms designating beneficiaries will remain in effect. 

EXCHANGE FORM 1700‐012 (DRAFT) ‐ Instructions 

Army and Air Force Exchange Service (AAFES)

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BENEFICIARY DESIGNATION
IMPORTANT CONSIDERATIONS WHEN CHOOSING BENEFICIARIES
AND PROVIDING INFORMATION
If you name any minor child as a beneficiary: The age at which a child becomes eligible to inherit
benefits directly may be different in each state. A guardian, conservator, or other legal representative
may have to be appointed by a court to receive property on behalf of a minor. You, your estate or other
beneficiaries may be required to pay legal expenses to make these arrangements. If you designate a
beneficiary who is a minor child at the time of your death, the benefits will not be paid to that child until
your estate provides the insurance company with a copy of the court order appointing a guardian,
conservator, or other legal representative for that minor child.

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To name a trust as beneficiary, please list the name and date of the Trust. Trust documents must be
attached and submitted with this form.

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To name your estate as beneficiary, please list “My Estate”.

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A married female should be designated by her given first name, not by her spouse’s given name. For
example, if you wish to list Mary E. Jones as your beneficiary, list her as Mary E. Jones, not Mrs. John
Jones.

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EXCHANGE FORM 1700‐012 (DRAFT) ‐ Instructions 

Army and Air Force Exchange Service (AAFES)
BENEFICIARY DESIGNATION
(Please print or type clearly)

OMB NO. 0702-0139
OMB approval expires
MMM DD, YYYY

Please read the Agency Disclosure Notice, Privacy Act Statement, and Instructions on the previous pages before completing.
Your Social Security Number and personal information is used to identify you and administer your employee insurance through AAFES payroll program. Failure to provide all
information may prevent you from receiving proper benefits. Please be sure to keep a copy of this form for your records.

SECTION I: PERSONAL AND EMPLOYMENT STATUS
NAME (LAST, FIRST, M.I.)

PRIOR NAME (i.e. Maiden)

Current Address (Street, City, State, Zip)

SOCIAL SECURITY NO.
BIRTHDATE (Day, Mo, Yr)

SECTION II: BENEFICIARY DESIGNATION; Complete this Section ONLY if you choose the SAME beneficiaries for all programs. (If more space is needed,
please present as an attachment to this form)
I designate the following beneficiary(ies), or those surviving beneficiaries who are living at my death, to share EQUALLY any Unpaid Compensation, Retirement Contributions, Life
Insurance (Basic and Supplemental), EMP Life Insurance (EMP Employees Only), or 401K Retirement Savings Plan.
BENEFICIARY NAME & SOCIAL SECURITY NO.
PERMANENT ADDRESS
BIRTHDATE
RELATIONSHIP
(Day, Mo, Yr)

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(Street, City, State, Zip)

Beneficiaries if all of the above are not living at my death:

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SECTION III: BENEFICIARY DESIGNATION; Complete this Section ONLY if you choose DIFFERENT beneficiaries for the individual programs.
OTHERWISE, ONLY COMPLETE SECTION II. (If more space is needed, please present as an attachment to this form)
SECTION III; PART A – UNPAID COMPENSATION BENEFICIARY
BENEFICIARY NAME & SOCIAL SECURITY NO.

PERMANENT ADDRESS

BIRTHDATE

(Street, City, State, Zip)

(Day, Mo, Yr)

RELATIONSHIP

Beneficiaries if all of the above are not living at my death:

SECTION III; PART B – RETIREMENT CONTRIBUTIONS BENEFICIARY (No retirement contributions are payable to a designated beneficiary as long as benefits are actually or
potentially payable to a surviving spouse)

BENEFICIARY NAME & SOCIAL SECURITY NO.

PERMANENT ADDRESS

BIRTHDATE

(Street, City, State, Zip)

(Day, Mo, Yr)

RELATIONSHIP

Beneficiaries if all of the above are not living at my death:

SECTION III; PART C – BASIC LIFE INSURANCE BENEFICIARY (two times annual salary)

PERMANENT ADDRESS

BIRTHDATE

(Street, City, State, Zip)

(Day, Mo, Yr)

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BENEFICIARY NAME & SOCIAL SECURITY NO.

RELATIONSHIP

Beneficiaries if all of the above are not living at my death:

SECTION III; PART D – SUPPLEMENTAL LIFE INSURANCE BENEFICIARY (more than two times annual salary)
BENEFICIARY NAME & SOCIAL SECURITY NO.

PERMANENT ADDRESS

BIRTHDATE

(Street, City, State, Zip)

(Day, Mo, Yr)

RELATIONSHIP

Beneficiaries if all of the above are not living at my death:

SECTION III; PART E – EXECUTIVE MANAGEMENT PROGRAM LIFE INSURANCE BENEFICIARY

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BENEFICIARY NAME & SOCIAL SECURITY NO.

PERMANENT ADDRESS

BIRTHDATE

(Street, City, State, Zip)

(Day, Mo, Yr)

RELATIONSHIP

Beneficiaries if all of the above are not living at my death:

SECTION III; PART F – 401k RETIREMENT SAVIGNS PLAN BENEFICIARY – PLAN NUMBER 83222. Use a whole % Only
BENEFICIARY NAME & SOCIAL SECURITY NO.

PERMANENT ADDRESS

BIRTHDATE

(Street, City, State, Zip)

(Day, Mo, Yr)

RELATIONSHIP

Beneficiaries if all of the above are not living at my death:

I UNDERSTAND THAT THESE DESIGNATIONS OF BENEFICIARIES SHALL OPERATE SO AS TO REVOKE ALL PREVIOUS BENEFICIARY DESIGNATIONS
MADE BY ME.
EMPLOYEE SIGNATURE
DATE (DAY, MO, YR)
WITNESS SIGNATURE (Other than Beneficiary)
DATE (DAY, MO YR)

EXCHANGE FORM 1700‐012 (DRAFT)