KIUC Linemen All Geared Up - Kauai Island Utility Cooperative

Request for Patronage Capital Refund
Please Print:
Name: _____________________________________________________________
Mailing Address: ____________________________________________________
City: __________________________ State: __________ Zip: _________________
Telephone Number: ( ) ______________________________
E­mail: ________________________________________________
KIUC Account No. _______________________________________
Social Security Number: ______________—_________—_______________
_______________________________________________ ___________________
Signature of Applicant Date
Select method of refund:
■ Apply refund to account ____________________________________
■ Request check refund
Mail to: Member Services – Patronage Capital
Kaua‘i Island Utility Cooperative
4463 Pahee St., Suite 1, Līhu‘e, HI 96766­2000
Office use only: Received ___________ Check # ________________ Amount $ ____________
Date Issued ____________ Initial ______ ID: _____
OCTOBER 2011 55