• CAPITAL CREDIT DISBURSEMENT AGREEMENT

    CAPITAL CREDIT DISBURSEMENT AGREEMENT

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    the signed below will be designated as the Capital Credit               Account Representatives.

  • All remaining Capital Credits will be paid out at a discounted rate, along with all outstanding checks, will be issued to each representative in equal shares.

  •           Discounted Capital Credit Total:                      *discounted amount is subject to change after 10/1/2024

  •       

                           Outstanding Check Total:

  • By the notarized signature(s) below, I/We agree to hold harmless and indemnify Heart of Iowa Communications Cooperative against all claims by virtue of the payment(s) on the fore mentioned account.

  • Subscribed and sworn to before me this

    _____ day of __________, 20____

     

    _________________________________

    Notary Public

    NOTARY SEAL

  • _________________________________________                            Signature

    _________________________________________                    Print Name

    _________________________________________                            Address

    _________________________________________                           City, State, Zip

  • Subscribed and sworn to before me this

    _____ day of __________, 20____

     

    _________________________________

    Notary Public

    NOTARY SEAL

  • _________________________________________                            Signature

    _________________________________________                    Print Name

    _________________________________________                            Address

    _________________________________________                           City, State, Zip

  • Subscribed and sworn to before me this

    _____ day of __________, 20____

     

    _________________________________

    Notary Public

    NOTARY SEAL

  • _________________________________________                            Signature

    _________________________________________                    Print Name

    _________________________________________                            Address

    _________________________________________                           City, State, Zip

  • Office Use Only:

    Received Date:

    Process Date:

    Employee:

     

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  • Should be Empty: