Capital Credits # A B C D E F G H I J K L M N O P Q R S T U V W Y Z IGAILER CARL MRS.ILER HENRYILER JOHNNYILER RONALD S.INDUSTRIAL ELECTRICAL ASSNINDUSTRIAL MACHINE AND FABINGLIS TIM WINGRAM CHARLES L.INGRAM FARM SUPPLYINGRAM JOE PONDINTERNATIONAL AGILE MFGINTERNATIONAL AGILE MFG PAYSTINTERNATIONAL AGIMFGINTERNATIONAL FOREST COINTERSTATE NATIONALEASEINVALID NAMEIRVIN NORISE CISBER JOHN JITT DATA CIRCUITITT DATA SETITT GRINNELLITT GRINNELL (PICKUP) #2ITT GRINNELL (WAGON) #1ITT GRINNELL GUARD SHACKITT GRINNELL INC.ITT GRINNELL PAGERITT GRINNELL-DIAL UP CIR.ITT GRINNELL, INC.ITT PAYSTATION (SHIPPING)ITT TELECOPIERIVEY CARLIVEY CARL V JRIVEY JOHN MIVEY JOHN MELVINIVEY JUANITAIVEY PAT BULLOCH TELEPHONE COOPERATIVE CLAIM FORM Existing Member Name(Required) First Last Existing Street Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Updated Name(Required) First Last Updated Street Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Account NumberMember NumberPhone NumberIn conjunction with the retirement of capital credits prior to 1990, I hereby make the following certification regarding my status or my entities status prior to receiving our patronage refund: I am a residential customer and have not deducted the cost of communication service on any tax return for the years prior to 1990. The qualified Member above is deceased and I am claiming the Patronage refund on their behalf. I have included a death certificate and a court document to verify that I am qualified to receive the refund and will distribute the proceeds according to the laws of Georgia. My entity is incorporated under the corporate laws of Georgia and our state issued control number below. Control NumberFile UploadMax. file size: 128 MB. Is there anything else you'd like to tell us?
