Gift And Disclaimer Of Interest In Performer Residuals (Performer)

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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
th
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

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