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.)

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.

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.

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Member's Consent

Other Member's Consent

Date

MonthDayYear

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