Assignment of Capital Credits Form

Name(Required)

First Last

I want to assign capital credits for the following years(Required)

I want to assign capital credits for the following reason:(Required)

To complete the early retirement process of capital credits for the estate of a deceased member

To donate all capital credits in my name to the GVEA Scholarship Disbursement Fund

Other - please describe

Member/Personal Representative Electronic Signature (Full Name)(Required)

Mailing Address of Member/Personal Representative(Required)

Street Address Address Line 2 City State ZIP Code

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Name

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