Utah State Firefighters' Association
Death Benefit Application
Name of Deceased
First Name
Last Name
Date of Death
-
Month
-
Day
Year
Date
Name of Beneficiary and Relationship to Deceased Member
Beneficiary Name
Relationship
Address of Beneficiary
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email of Beneficiary
example@example.com
Indicate if Current or Lifetime Member and ID#
Last Department the Member Worked For
Attach a copy of Members' Death Certificate or Published Obituary
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