You may also download the Certification of Assignment Form (PDF). Name(Required) First Last Name of Account(Required) I hereby make claims to the capital credits assigned by Golden Valley Electric Association, Inc. to the account named above for the following years:(Required) Furthermore, I hereby direct GVEA to distribute the capital credits to the following person/entity/organization:(Required) Consent(Required)I hereby certify and declare that: I am the party legally entitled to claim ownership of these capital credits and have directed GVEA to distribute the capital credits as noted in this document; I accept responsibility regarding any litigation which may arise from subsequent claims to these capital credits; and I understand that a copy of this certification statement will be released to any party making subsequent claim to these capital credits. I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.Claimant Electronic Signature (Full Name)(Required) Name of Person/Entity to Be Paid(Required) Mailing Address of Person/Entity to Be Paid(Required) Street Address Address Line 2 City State 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 ZIP Code CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
