Gift And Disclaimer Of Interest In Performer Residuals (Performer) printable pdf download

Gift And Disclaimer Of Interest In Performer Residuals (Performer)

Office Use Only:

Resid. Recv’d: Date_______ Action_______

Found. Recv’d: Date_______Action_______

Rev 4-2-12

GIFT AND DISCLAIMER OF INTEREST IN PERFORMER RESIDUALS (Performer)

I, _______________________________, whose social security number or federal tax identification number is

___________________, hereby irrevocably give, as a gift and without consideration, all of my right, title, and interest in any

residuals paid or to be paid in the future for my services as a performer to the following recipient:

Recipient or Charity Name:

__________________________________________________________

Address:

__________________________________________________________

City, State, Zip Code:

__________________________________________________________

Phone Number:

__________________________________________________________

Recipient’s SSN / CharityTax ID No:

__________________________________________________________

I also hereby disclaim any of my right, title, and interest in any residuals paid or to be paid in the future.

I hereby agree to mail or deliver a copy of this document to the above-referenced recipient. In the event I fail to mail or

deliver this document to the recipient, I hereby authorize the SAG-AFTRA to do so on my behalf.

Print Name:____________________________

Date:______________________

Signature:_____________________________

INDEMNITY AGREEMENT, INCLUDING AGREEMENT TO PAY ATTORNEYS’ FEES

By executing this Indemnity Agreement, I hereby agree to defend, indemnify and hold SAG-AFTRA, Inc. and any

payors of residuals harmless for any loss, liability, damage or costs, INCLUDING COURT COSTS AND ATTORNEYS’

FEES, that may arise from their reliance on this Gift and Disclaimer or any action to enforce this Agreement.

Print Name:__________________________________________________

Date:______________________

Signature:___________________________________________________

AREA BELOW FOR USE BY NOTARY PUBLIC ONLY

State of _______________________)

County of _____________________)

Subscribed and sworn to (or affirmed before me on this

______day of _____________________, 20_________,

by__________________________________________,

proved to me on the basis of satisfactory evidence to be

the person who appeared before me.

_____________________________________________

Place Notary Seal Above

Signature of Notary Public

855.SAG-AFTRA / 855.724.2387

Screen Actors Guild – American Federation of Television AND Radio Artists

5757 Wilshire Bl, 7

Floor * Los Angeles, CA 90036 * Tel. 323-549-6557 * Fax. 323-549-6550 *

Associated Actors and Artistes of America / AFL-CIO

Gift And Disclaimer Of Interest In Performer Residuals (Performer)

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