MBF CHANGE OF BENEFICIARY

MBF CHANGE OF BENEFICIARY

Be sure to fill out form completely and sign at the bottom for change to go into effect.
In accordance with the conditions of the Minister's Benevolent Fund of the Southern Missouri Distict Council of the Assemblies of God, I hereby revoke any previous designations of beneficiary and contingent beneficiary and designate as beneficiary and contingent beneficiary in event of my death the following:
Member Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
New Primary Beneficiary*
Relationship*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
New Contingent Beneficiary*
Relationship*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The right to change the beneficiary hereby designated without the consent of the said beneficiary is reserved.
SIGNATURE REQUIRED FOR CHANGE TO BE VALID.

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Signature*

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Signature date*
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