NEMR Payout Upon Death of Capital Credit Account Name fo Person to Receive Capital Credit Upon Death: (Payee#1)(Required) First Last Date(Required) MM slash DD slash YYYY DOB:(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Social Security Number(Required)Click the dropdown if there is more than one "Payee"NOYESName fo Person to Receive Capital Credit Upon Death: (Payee#1) First Last Social Security NumberDOB:MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name fo Person to Receive Capital Credit Upon Death: (Payee#1) First Last Social Security NumberDOB:MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920All Member's Signatures if living:I have advised them that they will need to contact Northeast Missouri Rural Telephone Company within 6 months after I am deceased to collect on my account. If I listed more than one payee, checks will be divided and issued to whom is left living.Living Member 1:(Required)Living Member 2:Living Member 3:For Help See Our FAQ Section FAQ Section Notary Public: (Will need to be taken to a Notary, signed and stamped) Δ
