Benevolent Fund Beneficiary Form-ASEA

Benevolent Fund Beneficiary Form

Use this form to designate or change your beneficiary

First name

Middle name

Last name

Agency or Retiree

Address

Email

Phone Number

Beneficiary 1

Beneficiary 1 Relationship

Beneficiary 1 Percentage

2

Beneficiary 2

Beneficiary 2 Relationship

Beneficiary 2 Percentage

2

Beneficiary 3

Beneficiary 3 Relationship

Beneficiary 3 Percentage

2

Your Signature

*

Be sure to save and print a copy of this form for your records. Your beneficiary can contact ASEA Member Services at 501-378-0187.

ASEA PO Box 1588 Little Rock, AR 72203