Single Membership Payable on Death Beneficiary Designation Form

Member Information

Name(Required)

Last 4 SSN(Required)

Account Number(Required)

Member Number

Service Address(Required)

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Consent(Required)

I designate the following as the beneficiary(ies) of my member credit account with Union Rural Electric Cooperative, Inc. to be paid up my death to:

Primary Designated Beneficiary:*

*Additional beneficiaries may be added below. If more than one primary beneficiary is designated, they will inherit equally.

Full Name or Trust Name(Required)

Address(Required)

Street Address City State ZIP Code

Phone(Required)

Relationship(Required)

Last 4 of SSN(Required)

Union Rural Electric Cooperative, Inc (URE) is authorized to register ownership of my member credit account with URE in my name and pay on death in accordance with the policies of the Cooperative to the primary beneficiary(ies) named herein or to the contingent beneficiary(ies) should all of the primary beneficiaries predecease me. This designation remains in effect until amended or revoked by me via written instructions to do so.

Choose your signature method(Required)

Draw Signature

Type Signature

Signature(Required)

Type your full legal name(Required)

Typed Signature Confirmation(Required)

I confirm that typing my full legal name above represents my signature and agreement to this form.

Date(Required)

Additional Primary Designated Beneficiary(ies):

Full Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Relationship

Last 4 of SSN

Full Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Relationship

Last 4 of SSN

Full Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Relationship

Last 4 of SSN

Contingent Designated Beneficiary(ies):

Full Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Relationship

Last 4 of SSN

Full Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Relationship

Last 4 of SSN

Security Check

Single Membership Payable on Death Beneficiary Designation Form

Member Information

Primary Designated Beneficiary:*

Additional Primary Designated Beneficiary(ies):

Contingent Designated Beneficiary(ies):

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