IATSE Local No.4

Beneficiary

Beneficiary First Name *

Beneficiary Last Name *

Relationship

Phone

Mailing Address *

City *

State *

Postal Code *

I have read and understand the death benefit form *

The undersigned member hereby acknowledges that he/she nor any of their beneficiaries have any vested right to receive or collect any death benefit payments from the local union, and that such payments are purely the voluntary action of the members of said Union which may be terminated at any time without prior notice.

Yes

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Theatrical Stage Employes Local No.4, IATSE

2917 Glenwood Rd
Brooklyn, New York 11210
(718) 252-8777