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NORTHWESTERN ELECTRIC COOPERATIVE, INC. Incomplete forms cannot be processed


October 2014 (NWEC only) Form rec’d by _____________


2925 Williams Avenue, Woodward, OK 73801


Phone (580) 256-7425 Fax (580) 254-2858 CAPITAL CREDITS ESTATE REFUND FORM


INFORMATION CONCERNING ______________________________________________, (NAME OF DECEASED MEMBER) I, ____________________________________ (your name) was personally acquainted with the above named decedent.


My relationship to said decedent is _________________________________ (friend, spouse, child, etc). Did decedent leave a Will? ____________If so, attach a copy of the Final Decree or Distribution of Decedent’s Estate I will be required to provide a certified copy of the death certificate. Can the Capital Credits be paid to the Estate of the Decedent? _______ Can the Capital Credits be paid to a Trust Account? _______ If so, name_______________________________________ Name of Decedent’s spouse_____________________________________ Is spouse still living? ________ On the back of this form or on a separate page, list the following:


1. Name and address of all children born to or legally adopted by decedent. 2. Name and date of death of any deceased children of decedent. 3. Name and address of any children of any deceased son or daughter (listed above). 4. If decedent left no surviving spouse or children, give the following information in the following order: Parents, if living; brothers and sisters, if died before decedent, list his/her children. If none of these, list surviving grandparents, nephews and nieces, uncles and aunts, cousins; if none, list nearest of kin.


I will indemnify, defend and hold NWEC harmless against any subsequent claim to or for these capital credit payments. I understand that a copy of this certification will be released to any party making subsequent claim of the capital credits. I am electing for this estate to receive a one-time refund of any unretired capital credits at a discounted present value rate.


____________________________________________ SIGNATURE OF CLAIMANT


______________ DATE


CITY


_________________________________ PHONE NUMBER OR EMAIL ADDRESS


______________________________________________________________________________________________ ADDRESS


STATE ZIP CODE


NOTARY: Signed or attested before me on this ___________day of _________________________, ___________. Notary Signature_______________________________________________________


(SEAL) FORM AND ATTACHMENTS WILL BE REVIEWED MONTHLY BY OUR ATTORNEY AND MANAGER, SUBJECT TO BOARD APPROVAL.


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