Form H0059, Notification of Annuity Remainder Beneficiary

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Effective Date: 7/2020

Updated: 7/2020

To notify the issuer of a disclosed annuity of the state's rights as the preferred remainder beneficiary.

Prepare an original and one copy of Form H0059.

Send the original of Form H0059 to the issuer of the annuity. File the copy in the case record.

Date — Self-explanatory.

Eligibility Specialist— Self-explanatory.

Office Address — Self-explanatory.

Phone Number — Self-explanatory.

Addressee — Enter the name and address of the annuity issuer.

Name of Applicant — Enter the applicant's name.

Date of Birth — Enter the applicant's date of birth.

Contract No. — Enter the contract number.