UNITED POWER, INC by 9kv3Z4MN

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									                                 Consent and Authority for
                Discounting Payment of Capital Credits for a Deceased Member


I, the undersigned, being first duly sworn on oath, depose and say:

That I am the heir/executor to the estate of _______________________, who as a patron of
United Power may be entitled to certain patronage capital credits for capital credit account
number _____________.

That I, as heir/executor, do hereby authorize United Power to discount and pay all the capital
credits that are due and payable. Payments shall be in accordance with the adopted policies of
the Board of Directors of United Power. I further agree to accept said sums in full settlement of
any and all amounts due.

That by this consent I hereby release United Power from any and all liability relative to the
discounted payment of capital credits and that I agree that said account shall be settled in full.


                ______________________________________________________________
                Signature                                       Date

                ______________________________________________________________
                Printed Name

                ______________________________________________________________
                Current Mailing Address

                __________________________________________________________
                City                            State             Zip

                _______________________________
                Contact Phone Number




Subscribed and sworn before me this _____ day of ____________, 2010. My commission

expires on________________________. Notary Public_________________________________




   Please return complete form to:   United Power, Inc
                                     P.O. Box 929
                                     Brighton, CO 80601
                                     Attention: Carmen Castillo

								
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