Capital Credit Claim Form

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CAPITAL CREDIT CLAIM FORM
2 S. West Street, P.O. Box 237, Cloverdale, IN 46120
765-795-4261 or 800-922-6677
Section I: To Be Completed by Claimant
By submitting this claim, Claimant affirms that all statements and information included herein are true and accurate, and the
Claimant agrees to hold Clay County Rural Telephone Cooperative, Inc. d/b/a Endeavor Communications, harmless from any
liability with regard to the disbursements of said capital credits.
1. Include a copy of your government issued photo identification , such as a Driver’s license, State ID, or a passport.
2. Member Name:_______________________________Signature:____________________________________________
3. Estate or Payee Name (if not member): ___________________________Signature:____________________________
4. Phone Numbers: Home____________________Work_________________________Mobile______________________
6. Member Date of Birth/Incorporation: ____________________ SSN/TIN: ____________________________________
7. Current Mailing Address: ___________________________________________________________________________
__________________________________________________________________________________________________
8. Previous Names/Aliases: ____________________________________________________________________________
9. Address(s) at time of active membership:_______________________________________________________________
__________________________________________________________________________________________________
10. Telephone Number(s) at time of active membership:____________________________________________________
11. Sign this Claim Form in the presence of a Notary Public and have Notary Public complete Section II and submit
the completed claim form to Endeavor Communications.
Section II: To be Completed By Notary Public
STATE OF ________________________________________)
) SS
COUNTY OF ______________________________________)
_________________________________________________________________ personally appeared before me and
(Claimant’s Name)
voluntarily executed the foregoing instrument on the____________ day of ______________________, 20_______.
Notary’s Signature_________________________________________
Notary’s Printed Name _____________________________________
S E A L
Notary’s County of Residence ________________________________
Notary’s Commission Expires ________________________________
Section III: To be completed by Endeavor Communications
Received in the mail by:_____________________________(must be notarized)
Received in the business office by:__________________________________
Customer is in good financial standing with Endeavor Communications: Yes
No
Member #_______________________________
Check Amount $_______________________
Verified By: _____________________________
Date Verified: __________________________

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