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

S E B HIGH SCHOOL PAY STA. #3

SABB, LENWARD

SABB, RONALD

SABOL WALTER

SACK H. A.

SACK H. A. CO.

SACK, H. A.

SACK, H. A. CO.

SACK, H. A. COMPANY

SADLER, VERNON D.

SALINSKI JAMES

SALINSKI WILLIAM

SALMEN, MICHELE

SALTER, SAMMY R.

SALZMAN FRANKLIN L

SAMMONS, COOPER

SAMPSON ANNIE MAE

SAMPSON IDORA

SAMPSON LEATHA MAE

SAMPSON OTIS L

SAMPSON, ARTHUR

SAMPSON, LILLIE MAE

SANCHEZ, GINA

SAND, CLEVE E.

SANDERS & SON'S TRUCKING

SANDERS AL K & KATHY

SANDERS CHARLES

SANDERS ELOISE C

SANDERS F. HUNT JR.

SANDERS PATSY

SANDERS SHARON

SANDERS SHURLING MEAT CO.

SANDERS, BENNIE T.

SANDERS, DALE O.

SANDERS, EUGENE

SANDERS, INMAN D.

SANDERS, J. W.

SANDERS, JAMES W.

SANDERS, JOANN

SANDERS, JOHN W.

SANDERS, KENNETH C. MRS.

SANDERS, L. E.

SANDERS, MARY G. MRS.

SANDERS, PAUL

SANDERS, PAUL III

SANDERS, RAY

SANDERS, ROBERT

SANDERS, STEVE

SANDERS, TENA

SANDERS, THOMAS E.

SANDERS, THOMAS E. TRUCKING CO

SANDERS, WILLIAM

SANDLIN FRANK

SANDLIN, LEWIS L.

SANDLIN, WILLIAM P.

SANDS VENDING

SAPP HENRY III

SAPP RICKY & ROBIN

SAPP, AMANDA

SAPP, CARL E.

SAPP, DORIS

SAPP, DOYLE

SAPP, STACIE P.

SAPPINGTON, WILLIAM

SARTEN, MICHAEL D.

SASSER, MURRAY B.

SATURDAY, THOMAS J.

SAULGOZIS, ANNA

SAUNDERS EMORY

SAUNDERS JAMES G

SAUNDERS, ERNEST

SAUNDERS, SANDRA

SAUNDERS, THURMAN MRS.

SAV'H ELECTRIC & POWER CO

SAXON SARAH

SAXON WILTON L.

SAXON, CLINTON R.

SAXON, EARL T.

SAXON, R. MICHAEL

SAXTON WILLIAM

SAXTON, BENNIE LEE

SAYRE, RANDOLPH E.

SCARBORO MAMIE J

SCARBORO, ALBERTA

SCARBORO, GEORGE MRS.

SCARBOROUGH J.A.

SCARBOROUGH, DAVID W. M.D.

SCATT, HARL H. JR.

SCEARCE, J. B. JR.

SCHAWE JAMES

SCHEARBACK ROBERT L

SCHEARBACK, WILLIAM L.

SCHEEL LILLIAN C

SCHEILF, BARBARA A.

SCHOCH, RICHARD NORMAN

SCHOENFIELD, DOTTIE K.

SCHOOL SUPT.

SCHRECOMGOST, NEAL

SCHUCK, CHARLES F.

SCHUMAN, LARRY C.

SCHUSTER, SIDNEY

SCHWAB, I.

SCHWALLS, SAM D.

SCONYERS JOHN

SCONYERS, LARRY

SCONYERS, ROY

SCOTT CARL

SCOTT CREEK FARM

SCOTT DEBRA

SCOTT J W JR

SCOTT JOEL L.

SCOTT JOHNNY & HAZEL

SCOTT KENT

SCOTT MARY

SCOTT MARY C

SCOTT PARKER

SCOTT SIDNEY W

SCOTT, CHARLES JAN

SCOTT, DONALD G.

SCOTT, E. M.

SCOTT, FAY

SCOTT, JOE

SCOTT, LISA

SCOTT, MRS. W. J.

SCOTT, MRS. WALTER J.

SCOTT, NEILY

SCOTT, P. O.

SCOTT, PHILLIP H.

SCOTT, RONNIE

SCOTT, ROSE (DUSTY)

SCOTT, RUTH

SCOTT, S. W. JR.

SCOTT, TERRY

SCOTT, WALTER

SCOTT, WALTER LOU

SCOTT'S VIDEO

SCREEN, BERNICE W.

SCREEN, J. R.

SCREEN, LT. COL. DONALD D.

SCREEN, SHANE

SCREEN, TOBY

SCREWBALL & HIS FRIENDS

SCREWS ROBERT L

SCROGHAM, PATTY

SCUDDER DANNY R

SEALS, JAMES J., JR.

SEAMANS LYNN D

SEAWRIGHT JAMES & LISA

SEB JR. HIGH PAYSTATION

SEEGERS, E. H. COM'D.

SEILER, MARK

SELECTIVE OFFICE SERVICES

SELF, DON R.

SELLARS, TONYA

SELLERS ALTON H

SELLERS LARRY

SELLERS W S

SELLERS, STACY

SERVICE AMERICA CORP.

SEVERENCE, THOMAS A.

SEXTON LETTIE

SEYMOUR GEORGE

SEYMOUR, BETTY

SEYMOUR, CLARKE E.

SHAFFER, VANCE A., JR.

SHARMAN, TRACY

SHARP LORI

SHARP MITCHELL C.

SHARPE, JAY

SHARPE, JOHN T.

SHATEEN, HENRY

SHATTEEN LAVON

SHATTEEN, HENRY, JR.

SHAW BILLIE

SHAW BROS OFFICE

SHAW BROS, FARMS

SHAW BROS.

SHAW BROS. OFFICE

SHAW EUGENE T

SHAW GRAIN CO. INC.

SHAW LORI I.

SHAW RAYMOND

SHAW SHANNON

SHAW, A. M.

SHAW, BILLY JOE

SHAW, BOTTIE H.

SHAW, CHARLIE A.

SHAW, CHARLIE H.

SHAW, E. D.

SHAW, EUNICE

SHAW, H. E.

SHAW, JOHNNY

SHAW, MRS. HATTIE

SHEALY, TROY W.

SHEARER BILLY

SHEAROUSE SARAH

SHEFFIELD & SON

SHEFFIELD JENNIFER

SHEFFIELD NANCY & PETE

SHEFFIELD SHIRLEY A

SHEFFIELD, A.J.

SHEFFIELD, AMY

SHEFFIELD, BERNICE

SHEFFIELD, CHARLIE C.

SHEFFIELD, HOLLY

SHEFFIELD, MARY

SHEFFIELD, RAYMOND L.

SHEFFIELD, SANDRA

SHEFFIELD, TEX

SHEFFIELD, TOM

SHELEY BETTY

SHELEY, DANNY

SHEPHERD, STEPHEN C.

SHEPPARD, BILL & CINDY

SHEPPARD, C. T.

SHEPPARD, CHARLES

SHEPPARD, JAMES

SHEPPARD, JOYCE

SHEPPARD, SIDNEY

SHERFFIELD, MARY

SHERMAN, EUGENE L.

SHERROD & SONS PIPE

SHERROD B E

SHERROD BOBBY

SHERROD, BENNIE

SHERROD, EDDIE

SHERROD, GEORGIA

SHERROD, HARRY T.

SHERROD, RUTH

SHERROD, WALLACE

SHERROD, WILLIAM R.

SHERROD, WINTON

SHINABERRY DEWAYNE

SHIPMAN C J

SHIRAH, GERRIE

SHIREMAN, JEFF

SHOEMAKE R NICHOLE

SHORE R W JR

SHORE SIDINA & R W JR

SHORE, CHARLES

SHOWALTER, MIKE

SHUG'S RESTAURANT

SHULTZ, HOUSTON G. SR.

SHUMAN B M

SHUMAN D E

SHUMAN DANA

SHUMAN FARM

SHUMAN GRADY

SHUMAN HOME IMPROVEMENT

SHUMAN ROBERT D

SHUMAN WILLIAM A JR

SHUMAN WILLIAM H JR

SHUMAN, APRIL

SHUMAN, DAVID & TINA

SHUMAN, DONNA

SHUMAN, GLENN

SHUMAN, H. D.

SHUMAN, H. DEAL

SHUMAN, JAMES ALLISON

SHUMAN, JESSE

SHUMAN, JOHNNY KARL

SHUMAN, PAUL

SHUMAN, R.L.

SHUMAN, RUSS

SHUMAN, SHELLIE

SHUMAN, WILLIAM A.

SHUMAN, WILLIAM A. JR.

SHUMAN, WILLIAM T.

SHUMANS DOROTHY

SHURLING MEAT CO.

SHURLING ROBERT

SHURLING, ERNEST R.

SHURLING, GLENN

SHURLING, MAUDE

SHURLING, MRS. ANNIE

SHURLING, T.E.

SHURLING, W. G.

SHYROCK, DANIEL L., SR.

SIDEWINDER RESTAURANT

SIKES HENRY

SIKES HERMAN M

SIKES TRACI M.

SIKES, CHARLES D.

SIKES, COY

SIKES, H. H.

SILLS JOSEPH B

SILLS WILLIAM B

SILLS, MARTHA D.

SILVER HAIR TRANS. CO.

SILVER ROY W

SIMMONS LONZIE

SIMMONS LOUIE F

SIMMONS MARTHA HERRINGTON

SIMMONS RANDALL V JR

SIMMONS RANDALL V. JR.

SIMMONS S

SIMMONS T C

SIMMONS THOMAS E

SIMMONS THOMAS E.

SIMMONS, DENT MRS.

SIMMONS, FRANK, SR.

SIMMONS, GLENN JR.

SIMMONS, GRACE

SIMMONS, H. G.

SIMMONS, I. V.

SIMMONS, LAURIE ANN

SIMMONS, LONZIE

SIMMONS, PAMELA A.

SIMMONS, R. MAC

SIMMONS, RALPH

SIMMONS, RUFUS MRS.

SIMMONS, RUTH B.

SIMMONS, SALLY

SIMMONS, T. C.

SIMMONS, THAD

SIMMONS, THOMAS E.

SIMPSON, KATHY

SIMS TRUCKING COMPANY

SIMS, DEWEY

SIMS, REX

SIMS, S. E., JR.

SINES SPENCER F.

SINGLETARY ELLEN

SINGLETARY SUSAN

SINGLETARY, SUSAN

SINGLETARY, TIMOTHY WYMAN

SISTRUNK, KENNETH

SITTON, LARRY D.

SIX R FARM

SKELTON, WILLIE

SKINNER ADA

SKINNER BERNADETTE

SKINNER ELIZABETH

SKINNER I L "TINK"

SKINNER R W

SKINNER, BEN L.

SKINNER, BEN RONALD

SKINNER, CARROLL

SKINNER, JANE MRS.

SKINNER, JOHN

SKINNER, WORTH

SKLAR DANIEL

SLAPPY, MRS. T. W.

SLATER, MRS. JULIA

SLATER, PETE

SLATER, RONNIE

SLATON JACKIE

SMALL ROBBIE & JANICE

SMALL, EMMA

SMALL, JUDY

SMALL, L. E. JR.

SMALL, W. A. (BILL)

SMALLWOOD, JOE L.

SMALLWOOD, RODNEY

SMALLWOOD, STEPHEN

SMILEY, AMY R.

SMILEY, DANNY

SMILEY, FERRELL E.

SMITH ALFRED

SMITH ALLISON

SMITH ANGELA V.

SMITH APRIL A.

SMITH CATHY E.

SMITH CHARLES E

SMITH COREY

SMITH DANNY PAUL

SMITH DOCK

SMITH DOROTHY MAE

SMITH ELIZABETH S

SMITH FRANK

SMITH FRED (DRYWALL)

SMITH GARNETT H.

SMITH GENERAL STORE

SMITH HAMP

SMITH HAZEL

SMITH HOMER

SMITH HOT & COLD PRESSURE WASH

SMITH JAMES WILLIE

SMITH JANICE

SMITH JERRY

SMITH JIMMIE LEE

SMITH JOHN

SMITH JOHN FRANKLIN

SMITH JOYCE

SMITH KARON F. PONDHOUSE

SMITH LAMAR JR

SMITH LESLIE

SMITH MARIE

SMITH MATTIE G

SMITH ROBERT D. JR.

SMITH RUBY M

SMITH SHERRY

SMITH T JEFF IV

SMITH TONY

SMITH TRAVIS WELDING AND

SMITH WALDEAN

SMITH WILLIAM

SMITH-HEALY FARMS INC FAX

SMITH, A. LEE

SMITH, ABBIE LEE

SMITH, ANGIE

SMITH, BARBARA ANN

SMITH, BERNARD

SMITH, BETTY BENNETT

SMITH, BETTY J.

SMITH, BETTY L.

SMITH, BOB

SMITH, BOBBY

SMITH, BROOKE

SMITH, CASHIE

SMITH, CHARLIE W.

SMITH, DELMAS A.

SMITH, DELORES

SMITH, DENNIS L.

SMITH, DOROTHY

SMITH, E. M.

SMITH, EDDIE

SMITH, EUGENIA

SMITH, FLOYD

SMITH, GEMMIE

SMITH, GERALD

SMITH, GLENET

SMITH, GRACE C. MRS.

SMITH, GREG

SMITH, HAROLD

SMITH, HAROLD E.

SMITH, HENRY

SMITH, HERBERT D. MD

SMITH, HERBERT L.

SMITH, ISOM

SMITH, J.

SMITH, J. A.

SMITH, J. WALTER

SMITH, JACK

SMITH, JACKSON JR.

SMITH, JAMES E., SR.

SMITH, JAMES EDWARD

SMITH, JAMES FOY

SMITH, JAMES H.

SMITH, JESSIE L.

SMITH, JO ALICE

SMITH, JOANNA

SMITH, JOHN A.

SMITH, JOHN E.

SMITH, JOHN R.

SMITH, JUDY

SMITH, KARON F.

SMITH, KATHRYN

SMITH, LARRY

SMITH, LARRY (TRAILER)

SMITH, LARRY D. & PEGGY

SMITH, LARRY MOBILE

SMITH, LAWRENCE E.

SMITH, LEE

SMITH, LESTER V., JR.

SMITH, LILLIE W.

SMITH, LYNN M.

SMITH, MARIE

SMITH, MARJORIE

SMITH, MARY ANN

SMITH, MAX E.

SMITH, MILLEDGE

SMITH, MRS. BOBBY E.

SMITH, MRS. GRACE C.

SMITH, MRS. JESSIE M.

SMITH, MRS. SIDNEY

SMITH, NOLA

SMITH, PALMER

SMITH, PAT

SMITH, PERRY L.

SMITH, PHIL

SMITH, PHYLLIS

SMITH, R. S.

SMITH, RAY

SMITH, REDIC FRANKLIN

SMITH, RICHARD

SMITH, RICHARD B.

SMITH, RICKY

SMITH, ROBERT L.

SMITH, ROBERT WAYNE

SMITH, ROGER

SMITH, ROOSEVELT

SMITH, ROY

SMITH, ROY L. (DRUG SUNDRIES)

SMITH, ROY LAUNDRY (PAY STATIO

SMITH, RUBY L.

SMITH, SARAH

SMITH, SHEILA

SMITH, STANLEY

SMITH, TOMMY

SMITH, TONY

SMITH, TRAVIS

SMITH, W. H. III

SMITH, W. H., SR.

SMITH, WARNELL

SMITH, WENDELL

SMITH, WILLIAM B.

SMITH, WILLIAM C., JR.

SMOAK, MARK

SNEED ELIZABETH

SNEED, HELEN

SNELLA ENTERPRISES INC

SNELLGROVE, BOBBY GENE

SNIPES BOBBY

SNIPES, A. R.

SNIPES, BOBBY

SNOW, CARL

SO. ATLANTIC CONFRENCE

SOLYER, LAVINIA PATSY

SORRELL JOHN T

SORRELL MICHAEL A

SORRELL, JOHN T.

SORROW, BARRY F.

SOUTH GEORGIA COMM.

SOUTH STEPHEN

SOUTHEAST BULLOCH DATA HIGH SC

SOUTHEAST BULLOCH GYM

SOUTHEAST BULLOCH HIGH GYM

SOUTHEAST BULLOCH JR. HIGH

SOUTHEAST BULLOCH LUNCH ROOM

SOUTHEAST GA TRUSS

SOUTHEAST GA. AUTO

SOUTHEAST GEORGIA BEEGLE CLUB

SOUTHEAST MACHINE CO.

SOUTHEAST TOOLS & BOLTS

SOUTHEASTERN MANAGEMENT COOP.

SOUTHERN AG AVIATION

SOUTHERN ASPHALT SEALING

SOUTHERN FRIED

SOUTHERN LINKS GOLF COURSE

SOUTHERN LINKS GOLF COURSE - F

SOUTHERN MAID

SOUTHERN MANAGEMENT COOP.

SOUTHERN MELON SERVICE

SOUTHERN STEEL

SOUTHERN STYLE B B Q

SOUTHERSTERN COMMODITY SERVICE

SOUTHWELL C L

SOUTHWELL ROBERT C & AMY

SOUTHWELL, C. W.

SOUTHWELL, KENNETH

SOWELL D.R.

SOWELL, J. G.

SPANDAU, KEN

SPANN, BETTY

SPANN, JOHNNIE

SPARHAWK, THOMAS G.

SPARKLEBERRY FARM

SPARKS IRENE

SPARKS, JIM

SPARKS, JIM (GROCERY)

SPARKS, MICHAEL A.

SPARKS, MRS. IRENE

SPARKS, MRS. RUBY

SPARROW WAYMON S.

SPAYO, DONALD L.

SPEAR, RONALD G.

SPEARS WILLIAM R

SPEER, MERRILL A.

SPELL C P SR

SPELL KYLE

SPELL, GLENN

SPELL, LARRY & LAURIE

SPELLS ANNIE MAUDE

SPELLS, BOBBY

SPELLS, FRANK JR.

SPELLS, M. L.

SPENCE CHARLENE

SPENCE FRANK

SPENCE GRADY L

SPENCE L E

SPENCE R E

SPENCE RALPH

SPENCE, W. FRANK

SPENCER, ANNIE

SPENCER, EDWARD D. JR.

SPENCER, EDWARD D., SR.

SPENCER, JAMES L.

SPERANZA BETTY J

SPIKES, DONNA

SPIVEY B F

SPIVEY, DAVID E.

SPIVEY, JAMES G.

SPIVEY, TAMMY RENEE

SPRAGUE MARY

SPRAGUE, TREMPER JR.

STAFFORD, CARRIE

STAFFORD, DANIEL

STAFFORD, MITCH

STALCUP SMALL ENGINE REPAIR

STALCUP, B. S.

STALCUP, DEBORAH

STALCUP, JOHN RAY

STALCUP, NANCY H.

STALCUP, W. L.

STALLINGS JACK

STALLINGS, GEORGE

STAMBUK, ROBERT B. M.D.

STAMBUK, ROBERT B., MD

STANLEY FRANKIE

STANLEY, ELLEN

STANTON, COURTLAND A.

STANTON, GRACE E.

STARLING JENNY

STARLING PLUMBING & ELECTRICAL

STARLING R KEVIN

STARLING SCOTT

STARLING WILLIAM J

STARLING, DEWAYNE

STARLING, JUDY E.

STARLING, JULIUS M.

STARLING, M. N.

STATESBORO AIRPORT COMMITTEE

STATESBORO BBS NODE 1

STATESBORO CARPET & TILE

STATESBORO DENTAL ASSOC

STATESBORO ORTHOPAEDICS PC

STATESBORO PLUMBING AND ELECTR

STATESBORO RADIOLOGY

STATESBORO REALTY

STATESBORO SHRINE CLUB

STATESBORO TELEPHONE COMPANY

STATESBORO TRANSFER STORAGE

STATESBORO WASTE TREATMENT PLT

STATESBORO WINNELSON RETAIL

STATESBORO-BULLOCH CITY PARKS

STATESBORO-BULLOCH COUNTY

STATESBORO-BULLOCH CTY PK & RE

STAUFFER, LYNDA

STEED, CINDY

STEELE LILLIAN

STEELE, FLOYD

STEIN, JIM

STEINER, DOUG

STEPHENS LOTTIE B

STEPHENS RAY

STEPHENS, ALLEN L.

STEPHENS, CHERYL

STEPHENS, DAN L.

STEPHENS, JAMES C.

STEPHENS, W. W.

STERLING, SCOTT

STERMER, JOSEPH

STEVENS, IAN R. SGT.

STEVENS, J. P. AND CO. INC.

STEVENS, SANDRA

STEVENS, TRESEA

STEVENS, TRESEA H.

STEWART & ASSOCIATES CONST INC

STEWART E M

STEWART J C

STEWART J T

STEWART MARIE

STEWART, CHARLES

STEWART, CHARLES JR.

STEWART, DANIEL

STEWART, DANIEL WAYNE

STEWART, GENE

STEWART, H.E.

STEWART, HERBERT

STEWART, HUBERT, JR.

STEWART, INMAN

STEWART, IVY LEE

STEWART, J. E.

STEWART, LEE

STEWART, LEWIS

STEWART, MRS. E. E.

STEWART, MRS. J. A.

STEWART, OSCAR DAVID

STEWART, ROBERT C.

STEWART, W. JOHNNY

STIDEM JAMES W

STILL, GUY

STILL, GUY G.

STILLS, ANNA

STILLWELL, GLENN

STILSON CAFE

STILTS, DAVID

STINSON B-B-Q

STOKES MARVIN

STOKES MISSY

STOKES, MARVIN

STOKES, RON

STOKES, STELLA H.

STOKES, W. M. BRUCE

STONE JAMES K JR

STONE PRODUCTS, INC.

STONE, DAVID K.

STONE, HENRY

STONE, MICHAEL

STONE, NELL S.

STONER, DONALD E.

STOWER, CARLOS N.

STRADLING, WILLIAM H.

STRANGE LOUISE

STRANGE, SHIRLEY

STRANGE, Z. L. JR.

STRICKLAND HUGH S

STRICKLAND LONNIE M.

STRICKLAND, CHARLES M.

STRICKLAND, CHERRY

STRICKLAND, DRENNON

STRICKLAND, EMMIE L.

STRICKLAND, F. H.

STRICKLAND, FLOYD

STRICKLAND, GEORGE E.

STRICKLAND, JAMES H.

STRICKLAND, JASON H.

STRICKLAND, JIM H.

STRICKLAND, JOHN M.

STRICKLAND, MARC

STRICKLAND, SUNSET CARSON

STRICKLAND, TONY E.

STRICKLAND, WILLIAM A.

STRICKLAND, WILLIE

STRINGER, JOAN

STRINGER, W. C.

STRONG AUGUSTUS & MARTHA

STROUSE, THOMAS M.

STROZZO BENNY

STROZZO EQUIPMENT CO.

STROZZO GERALD

STROZZO PECAN RIVERHOUSE

STROZZO, ANDREW

STROZZO, DOMINIC

STROZZO, JERRY

STROZZO, LILLIE

STROZZO, SALVATORE

STROZZO, TONY

STUART, LEROY

STUBBS, TERRI

STUCKEY N B

STUCKEY RURAL DEVELOPMENT

STUCKEY RURAL DEVELOPMENT CORP

STUCKEY RURAL DEVELP. CORP.

STUCKEY, JOSEPH J.

STYLE SHOP

SUB SHOP OF BROOKLET, THE

SUDDATH, HUNTER

SUDDATH, PAUL

SUDDETH DON

SUDDETH JAMES A.

SULLINS, VICKI

SULLIVAN ENVIRONMENTAL SERVICE

SULLIVAN, ED

SUMMER HILL BAPTIST CHURCH

SUMNER DOROTHY VIVIAN

SUMNER, FREDDY

SUMPTER, SHIRLEY

SUTHERLAND TERRY

SUTTER, R. TODD

SUTTON, DANIEL J.

SUTTON, DONALD

SUTTON, GEORGE

SUTTON, LOUISE

SWAIN, HENRY R.

SWAN, HENRY

SWART, JAMES & MARIE

SWEAT JOHN H

SWEAT, JAMES D.

SWEAT, JAMES S.

SWEAT, JOHN W.

SWEAT'S BAR-B-Q

SWEENEY DORIS S

SWEET'S FUR & METALS CO INC

SWILLEY DELL L.

SWIMPLY'S

SWINSON, PENNIE

SWINT ALLEN

SWINT BROS. SERVICE STATION

SWINT UTILITIES

SWINT, A. J. & W. A. HOG BARN

SWINT, ROBERT

SWINT, RONNIE

SYKES, & CO. INC.

SYKES, PELEM III

SYKES, S. P.

BULLOCH TELEPHONE COOPERATIVE CLAIM FORM

Existing Member Name(Required)

First Last

Existing Street Address

Street Address Address Line 2 City State ZIP Code

Updated Name(Required)

First Last

Updated Street Address(Required)

Street Address Address Line 2 City State ZIP Code

Account Number

Member Number

Phone Number

In 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 Number

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