Memorial Donation Request

Paug-Vik Incorporated Limited will provide a payment of up to $1,000 as a result of the death of shareholder. A payment of up to $500 for a spouse of shareholder (a person who is legally married to shareholder on the date of death) or child of shareholder (direct lineal or legally adopted child).

The request for payment of funeral expenses must be made within 60 days after the death of shareholder, spouse or child.

Name of the Deceased

Date of Birth

Date of Passing

Payable to (Name of Business or Person)

Mailing Address

City

State/Province

Zip/Postal

Phone

Payable for (Funeral Expense)

Paug-Vik Incorporated Limited reserves the right to question the reasonableness of any payment request and reserves the right to make full or partial payments, or to deny any payments in its sole discretion.

Certification

By my signature below, I certify that the funds received are to help pay for funeral related expenses.

When necessary, verification documents will be requested to process payment.

Name of Applicant

Signature

Clear

Date

Relation to the Deceased