Death Benefit Assignment

I hereby authorize and direct Office and Professional Employees International Union, Local #2 to pay, upon death, the benefit provided in Article IX of said Local Union’s Constitution to:

NAME OF BENEFICIARY: ___________________________________________________

RELATIONSHIP OF BENEFICIARY: __________________________________________________

ADDRESS:

I further declare it is my intention to cancel any and all prior assignments of said benefit.

PRINT NAME: ____________________________ MAIDEN NAME:_______

ADDRESS: _________________________________________________

MEMBER’S SIGNATURE: ______________________________________

SOCIAL SECURITY NUMBER: ______________________ DATE:

PLEASE MAIL OR FAX THIS FORM TO:

Local 2 OPEIU

8455 Colesville Road Suite 1250

Silver Spring, MD 20910-3320

ATTN:  Rachel Gore

Fax: 301-608-2586