Name Removal Form | Osage Valley Electric Cooperative Association

Name Removal Form

Date / Time

Name *

Contact Number *

Membership Number *

Account Address

Address Line 1

Address Line 2

City

State

Zip Code

I understand that having my name removed from the account number above will eliminate any responsibility for charges incurred on this account from this point forward. I also understand that I give up any rights to the deposits and/or capital credits connected with this account.

Signature *

Please include a copy of your driver’s license before submitting this form. *

Click or drag a file to this area to upload.

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