Request for retirement of deceased member equities

The undersigned (Personal Representative or Legal Counsel for Personal Representative or Spouse/Guardian) of the above named deceased member, does hereby request that the Board of Directors of United Quality Cooperative approve the retirement of the member equities, and that UQC issue its check for the total combined equities and that the same be issued payable as listed below.

Name of deceased member

Date of death

MM

DD

YYYY

Last 4 digits of social security #

UQC Account Number

Name to appear on the check

Mailing Address, City, State, Zip Code

Where should we send the check?

Phone

(###)

###

####

Email

Electronic Signature

Please type in your full name in lieu of a signature

Today's date

MM

DD

YYYY

In addition to this form, please email a copy of the death certificate as well as a copy of the personal representative paperwork to KALIM@UQCOOP.COM

Please type "YES" in field below

Request for retirement of deceased member equities

Thank you! Kali will be in contact with you soon!