Deceased Member Account/Check Processing - Great Lakes …

DECEASED MEMBER ACCOUNT/CHECK PROCESSING:

This form is for deceased member account processing for Great Lakes Energy. Please fill out if the payee

on the refund check is deceased. In order to induce Great Lakes Energy to pay me the Capital Credits due to

Payee Name On Check

,I

agree to hold Great Lakes Energy

Your Name

harmless from the claims of any other individuals entitled to share in such refund.

Enter account number of the payee as shown on check:

Enter your relationship to the payee on the check:

Select your payment method:

Check

Credit my Great Lakes Energy account. Enter account number:

Donate the full amount to the Great Lakes Energy People Fund to help local nonprofit organizations.

Please PRINT your information:

Name:

Mailing address:

City:

State:

Zip:

Phone Number:

Driver¡¯s License Number:

Signature:

Date:

Return this fully completed form and the original check to:

Great Lakes Energy, P.O. Box 70, Boyne City, MI 49712

or return in person to a local Great Lakes Energy office.

Please note, you MUST include the original check with this form in order for

the refund check to be reissued.

Questions? Contact us at 888-485-2537 or email billing@.

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