Request for Membership Change Deceased Member with Surviving Spouse

Joint Memberships

Request for Membership Change Deceased Member with Surviving Spouse

Please fill out the webform below OR the PDF here.

The undersigned does hereby release and surrender to Clark Energy Cooperative all rights to
Membership Certificate shown as:

Existing Membership Certificate

Name:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

The undersigned does hereby apply for membership as follows as spouse is deceased:

Requested Membership Certificate

Name:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

The undersigned also requests any capital credits and records associated with capital credits on the released certificate be assigned, transferred, and kept with the newly requested member certificate.

Surviving spouse (please sign here)

Sign above

Date of Death of Deceased Spouse

Member #:

Member's SS# (last four digits):

Member's DL #:

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