AGVA WELFARE TRUST FUND
DEATH BENEFIT DESIGNATION

DATE____________________________

PERFORMER’S LEGAL NAME__________________________________

PERFORMER’S STAGE NAME__________________________________

ADDRESS____________________________________________________

_____________________________________________________________

_____________________________________________________________

DATE OF BIRTH______________________________________________

MALE___________FEMALE_________

SOCIAL SECURITY #__________________________________________

AGVA MEMBERSHIP #________________________________________

I do hereby designate my beneficiary (ies) to receive benefits payable upon my death. This designation supercedes all (if any) previous designations.

PRIMARY BENEFICIARY______________________________________
(please use full name)
BENEFICIARY SOCIAL SECURITY #____________________________

RELATIONSHIP_______________________________________________

ADDRESS____________________________________________________

_____________________________________________________________

_____________________________________________________________

PHONE NUMBER_________________________

DATE OF BIRTH__________________________

MEMBER’S SIGNATURE_______________________________________


MEMBER CHANGE OF ADDRESS
CHANGE OF EMAIL ADDRESS


TODAY’S DATE_______________________


LEGAL NAME______________________________________________


STAGE NAME______________________________________________


SOCIAL SECURITY NUMBER________________________________


AGVA MEMBERSHIP NUMBER_______________________________


CURRENT EMAIL ADDRESS__________________________________

OLD ADDRESS______________________________________________

______________________________________________

______________________________________________


NEW ADDRESS______________________________________________

______________________________________________

______________________________________________



Please mail this completed form to:

American Guild of Variety Artists
363 Seventh Avenue – 17th floor
New York, New York 10001
ATT: Membership Department