Designation of Beneficiary

Designation of Beneficiary of Capital Credits

Missouri Uniform TOD Security Registration Act 461.028

Member Information:

Member Name*

First NameLast Name

Social Security Number*

Other Member (if a shared account)

First NameLast Name

Member Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState

Zip Code

I, Member Name / Other Member (if a shared account) of Address pursuant to the terms of the Uniform TOD Security Registration Act, designate the following as the beneficiary of my capital credit account with White River Valley Electric Cooperative to be paid out after my death and when the board of directors selects the manner, method, and timing of payment:

Primary Designated Beneficiary:

Primary Designated Beneficiary Name*

First NameLast Name

Social Security Number*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone*

Area CodePhone Number

Email*

example@example.com

Date of Birth*

MonthDayYear

Relationship*

Would you like to name a secondary designated beneficiary? (If the primary beneficiary predeceases the member/s, the secondary beneficiary accedes to the primary position.)*

YesNo

Secondary Designated Beneficiary:

Secondary Designated Beneficiary Name:*

First NameLast Name

Social Security Number*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone*

Area CodePhone Number

Email*

example@example.com

Date of Birth*

MonthDayYear

Relationship*

White River Valley Electric Cooperative is authorized to register ownership of my capital credit account with WRVEC in my name and pay out after my death and when the board of directors selects the manner, method, and timing of payment to the primary beneficiary named above or to the secondary beneficiary should the primary predecease me. This designation remains in effect until amended or revoked by me via written instructions to do so.*

I Understand

Would you like to donate your capital credits to Operation Round Up? Every penny raised is used to support charitable causes, programs and services in our area.*

Yes, donate all current and future capital credits.Yes, I'd like donate 100% of current year's capital credits.Yes, I'd like to donate a portion of current year's capital credits.No, not at this time.

How much would you like to donate?*

Submit:

To obtain electronic communications and submit your application, indicate your consent to the terms and conditions of the Electronic Communications Consent and Charity Tracker ROI by clicking “I Accept.”

Member's Consent*

I Accept

Other Member's Consent*

I Accept

Date*

MonthDayYear

Please verify that you are human*