Transfer On Death Form
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5TRANSFER ON DEATH FORM
Sign and return original form to US Energy Development Corporation at 2350 N Forest Rd, Getzville NY 14068.
For assistance, please contact the Investor Relations desk at 800-636-7606 x349
A. INVESTOR INFORMATION
Investor(s) Name:
Social Security Number / TIN:
City
State:
Street Address:
Zip Code:
Program(s) Invested In (Include # of Units)
_________________
_________________
_________________
_________________
_________________
B. DESIGNATE YOUR BENEFICIARY
Primary Beneficiary:
Upon my death, the beneficiary shall be:
Owners/Trust Name:
% Ownership:
Relationship:
Type:
Individual
Partnership
Corporation
Other: _________________
City
State:
Street Address:
Zip Code:
Social Security Number / TIN:
Telephone Number:
C. DESIGNATE YOUR BENEFICIARY
(If % Ownership listed in Section B does not total 100%)
Primary Beneficiary:
Upon my death, the beneficiary shall be:
Owners/Trust Name:
% Ownership:
Relationship:
Type:
Individual
Partnership
Corporation
Other: _________________
State:
City
Street Address:
Zip Code:
Social Security Number / TIN:
Telephone Number:
_________________
Continued on Page 2
Rev. Date: 01/14
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