DATE________________
REQUEST FOR CAPITAL CREDITS
****HAVE YOU EVER BEEN A CHUGACH ELECTRIC MEMBER? IF YES, PLEASE COMPLETE SECTION I****
*** IF YOU ARE MAKING THIS REQUEST ON BEHALF OF A DECEASED MEMBER, COMPLETE SECTION II ***
SECTION I – MEMBER INFORMATION
TYPE OF ACCOUNT: RESIDENTIAL BUSINESS
MEMBER NAME (Last, First, MI)
OTHER NAMES YOU MAY HAVE USED
CURRENT MAILING ADDRESS
MEMBER NUMBER MEMBER SSN
CONTACT NUMBER EMAIL ADDRESS
WHAT YEARS OF SERVICE WITH CHUGACH ELECTRIC?
SECTION II – DECEASED INFORMATION
NAME OF DECEASED MEMBER ______________________________________________________________________
SUBMITTED BY (Last, First, MI) ___________________________________________________________________
MAILING ADDRESS
CONTACT NUMBER EMAIL ADDRESS
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ESTATE DEATH CERTIFICATE ENTITLEMENT OTHER LEGAL DOC
REP NAME DATE