Deceased Payment Option

Dear Claimant:

This form acknowledges your request for payment of the assigned capital credits of Haywood Electric Membership Corporation allocated to this deceased member.

The Capital Credits allocated on the books of HEMC to :

CIN#

Deceased Member Name

Choose One:

I request payment for all Capital Credits assigned through December 31, 2020. I realize that this payment will forfeit all patronage assignments for the year 2021.

I request payment in approximately June 2022 for all Capital Credits assigned through December 31, 2021

Can be paid in two (2) ways. I/We, the undersigned representative(s) or heir(s) of such decedent's estate do hereby make a one-time irrevocable decision on how to receive this money by selecting and executing one of the following choices:

IN WITNESS, WHEREOF, the undersigned sign(s) this document on

Claimant Signature

Sign above

Claimant Address

Address

Address Cont.

City/Town

State/Province

ZIP/Postal Code

Witness Signature

Sign above

Witness Address

Address

Address Cont

City/Town

State/Province

ZIP/Postal Code

Reminder: In all circumstances, the check will be made payable to the Executer or Administrator if appointed.

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CUSTOMER SERVICE: 1.800.951.6088

Deceased Payment Option