To: Your Bank's Name

Address

City, State, Zip Code

In accordance with Wisconsin State Statute 445.125, 1 hereby instruct you to change the beneficiary funeral home on the funeral trust, casket trust and/or vault trust and/or any other related documents or policies (whichever is applicable) for John Doe from XYZ Funeral Home, 123 Anystreet Avenue, Sometown, YZ 12345 to Picha Funeral Home, 120 East Adams Street, Lake Delton, WI 53940-0757. As of this date, I hereby designate Picha Funeral Home as the new beneficiary of said trusts and/or other related documents or policies.

I do further certify that I have, pursuant to Wisconsin State Statute 445.125 (d), previous to this designation, given written notice in the form of a copy of this document to the current, former beneficiary of this change.

John Doe

(Depositor Name and Signature) (Date)

Jane Doe

(Witness Name and Signature) (Date)