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Home
About
Membership
- Membership
Services
Retirees
More Info
- News
- Events
Contact
More

Use tab to navigate through the menu items.

1301 West 7th St. Little Rock, AR 72201 (501) 378-0187

Funeral Assistance Beneficiary Form

Use this form to designate or change up to 3 beneficiaries

First and MI*

Last*

Agency OR Retired

Member or Personnel #

Address

Email

Phone

Beneficiary 1*

Beneficiary 1 Relationship*

Beneficiary 1 Percentage*

Beneficiary 2*

Beneficiary 2 Relationship*

Beneficiary 2 Percentage*

Beneficiary 3*

Beneficiary 3 Relationship*

Beneficiary 3 Percentage*

Before you submit:

Are your beneficiaries at least 18 years of age?

Do your percentages, when added together, equal100?

Please send me a PDF copy of this form for my records

Signature

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Beneficiaries: Please contact ASEA at 501-378-0187 for assistance.

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