UFCW LOCAL 555 BENEFICIARY CARD

Member’s Name:_______________________________ SS #__________________________

Signature_______________________________________ Date:________________________

I hereby designate ______________________________________________________________

(Print Name)

SS #___________________________________ Date of Birth: _______________

Relationship___________________________________________________________________

Address:_____________________________________________________________________

_____________________________________________________________________________

^{City State Zip}

To receive such benefits from UFCW 555, as may be payable because of my death.

This designation shall be effective until changed in writing by me.

Please complete and Return to: UFCW 555

PO BOX 23555

Tigard OR 97281-3555