Capital Credit Claim Form

This form is to be used when claiming capital credits that have been issued in your name. You can use this
form if your spouse is deceased and your name was also on the account. Claims being made by heirs or
spouses whose names were not on the account require a different form; the Agent’s Appointment Form. If
you still have the capital credit check, return it to us with this form. If you are mailing this form back to us,
please include a copy of your driver’s license or government issued id for identity verification.

Please print all information.

Claimant Info:

Name(Required)

First Last

Current Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

REMC Capital Credit Account Info:

Name(s) on account

Name(Required)

First Last

Name

First Last

Last 4 digits of Social Security number for name(s) on account(Required)

Is the address of the account(s) the same as the current address?

Yes

Address(Required)

Street Address Address Line 2 City State ZIP Code

What years were you served by REMC?(Required)

By signing this form you are stating that the above information is accurate and truthful and that you are claiming Jasper County REMC capital credits that you are entitled to.

Claimant Electronic Signature (Full Name)(Required)

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Claimant Info:

REMC Capital Credit Account Info:

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