Please complete form online and mail completed form to: Haywood EMC 376 Grindstone Road Waynesville, NC 28785 Immediate Payment At Present Day Value With Assignment Of The Remainder To Haywood EM Deceased Member Claim Form I/We agree to accept immediate payment of the present day value of all patronage capital credited. Payment in this manner allows the Cooperative to pay both living members and estates on an equal value basis. This will have the effect of "clearing out" the deceased member's account both for the estate administrator and the Cooperative. In accepting this payment, I/We, the undersigned representative(s) or heir(s) of such decedent's estate hereby irrevocably assign the Cooperative the portion of such credits no so paid to include any patronage capital credited to the decedent as a result of patronage or similar credits being realized by the Cooperative from any cooperative affiliated organization. IN WITNESS, WHEREOF, the undersigned sign(s) this document on Claimant's Signature Reset Sign above Claimant's Name Claimant Address Address Address Cont City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Witness's Signature Reset Sign above Witness's Name Witness Address Address Address Cont City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Effective January 1, 2001 CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit Leave this field blank