AGVA WELFARE TRUST FUND
DEATH BENEFIT DESIGNATION
DATE ____________________________

PERFORMERíS LEGAL NAME ______________________________________________________
PERFORMERíS STAGE NAME _____________________________________________________
ADDRESS _____________________________________________________________________
_____________________________________________________________________________
PHONE & CELL PHONE NUMBERS__________________________________________________
EMAIL ADDRESS________________________________________________________________
SOCIAL SECURITY # __ __ __-__ __-__ __ __ __ AGVA #_______________________________

This designation supercedes all (if any) previous designations.

PRIMARY BENEFICIARY __________________________________________________________
(please use full name)
DATE OF BIRTH _______________________________________________________________
RELATIONSHIP _________________________________________________________________
SOCIAL SECURITY # ___ ___ ___ - ___ ___ - ___ ___ ___
ADDRESS_________________________________________________________________________________________________________________________________________________
____________________________________________________________________________
PHONE & CELL NUMBERS _______________________________________________________
EMAIL ADDRESS_______________________________________________________________
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SECONDARY BENEFICIARY_______________________________________________________
(please use full name- OPTIONAL-PLEASE DESIGNATE ONLY IF YOU WISH THE BENEFIT TO BE DIVIDED BETWEEN TWO DIFFERENT PEOPLE)
DATE OF BIRTH _______________________________________________________________
RELATIONSHIP _________________________________________________________________
SOCIAL SECURITY # ___ ___ ___ - ___ ___ - ___ ___ ___
ADDRESS_________________________________________________________________________________________________________________________________________________
____________________________________________________________________________
PHONE & CELL NUMBERS _______________________________________________________
EMAIL ADDRESS_______________________________________________________________
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MEMBERíS SIGNATURE __________________________________________________________