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242 24th
Ave. N.W. PO Box 1208 Norman, OK 73070 (405) 321-2024 Fax (405) 217-6900 CERTIFICATION OF ENTITLEMENT TO OKLAHOMA ELECTRIC COOPERATIVE CAPITAL CREDITS
I, __________________________________________, hereby make claim to the capital credits assigned by Oklahoma (PLEASE PRINT FULL NAME)
Electric Cooperative to the account of ________________________________________________________________ . (NAME OF DECEASED AND/OR NAME OF BUSINESS OF DECEASED)
DECEASED SSN
I certify that: 1)
2) 3) 4) 5) DOB DOD
I am the party legally entitled to claim ownership of these capital credits payments because ___________________________ ____________________________________________________________________________________________________;
I will be responsible for distributing the capital credits claimed in accordance with any predetermined agreements of the business to which they were assigned, or the will of the deceased member;
I will indemnify, defend and hold Oklahoma Electric Cooperative harmless against any subsequent claims to or for these capital credits payments.
I understand that a copy of this certification statement will be released to any party making subsequent claims to these capital credits;
I will be required to provide a certified copy of the death certificate to Oklahoma Electric Cooperative, if the member eligible for capital credits is now deceased.
________________ SIGNATURE OF CLAIMANT ADDRESS PHONE NUMBER(S) STATE OF OKLAHOMA COUNTY OF _______________ DATE
SOCIAL SECURITY NUMBER OR FEDERAL ID ________________
CITY STATE
_________________________________________________________________________________________________ EMAIL ADDRESS
ACKNOWLEDGMENT
) ) )
ss.
Before me________________________, in and for this state, on this ______day of ________________, 20__, personally appeared _________________________________to me known to be the identical person(s) who executed the within and foregoing instrument, and acknowledged to me that _____executed the same as ______free and voluntary act and deed for the uses and purposes therein set forth.
_____________________ Notary Public
My Commission Expires:________________
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