Capital Credits Paid to Sole Heir Agreement

CAPITAL CREDITS PAID ITO SOLE HEIR AGREEMENT
I,
being first duly sworn state:
1. I am the sole heir of
I state affirmatively that no persons other than myself have a right or interest in his/her assets.
2. There will be no probate for the Estate of
3. I am requesting the discounted capital credits, representing the full and complete payout, of
and the total outstanding checks of
issued by Heart of Iowa Communications Cooperative on the account(s) of the predecessor be made payable to me,
4. Further I agree to hold harmless and indemnify Heart of Iowa Communications Cooperative against any and all claims by virtue of the payment of the discounted capital credits owed on the account of
Address

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_________________________________________ Signature
Subscribed and sworn to before me this

_____ day of __________, 20____

_________________________________

Notary Public

NOTARY SEAL
Should be Empty:

CAPITAL CREDITS PAID ITO SOLE HEIR AGREEMENT