Synchrony Bank Estate Distribution Instruction Form

P.O. Box 105972, Atlanta, GA 30348-5972
Synchrony Bank Estate Distribution Instruction Form
Please complete the applicable sections below, sign before a notary and return BOTH pages to Synchrony Bank.
Failure to return both pages of this form will result in a delay in processing your distribution.
By signing this document, the Executors named below certify and direct that:
THIS FORM IS FOR THE FOLLOWING DECEASED CUSTOMER AND ACCOUNT(S):
Synchrony Bank Account Number:
Customer Name
Customer’s Last Address
City
State
ZIP Code
THE CURRENTLY SERVING EXECUTORS OF THE ESTATE OF THE CUSTOMER ARE:
Executor Name
Phone Number
Executor Address
City
Executor Name
State
ZIP Code
Phone Number
Executor Address City State
ZIP Code
(If there are more than two Executors signing the form, please copy and have the additional Executors sign a separate form.)
(1)The Customer was not domiciled in the state of New Jersey within the last five years; or if the customer was domiciled in New
Jersey within the past five years, describe how and when the customer changed domicile.
(2)Any and all debts, taxes and claims against the customer’s Estate have been paid or provided for, and Executor(s) will refund to
Synchrony Bank, any amounts erroneously distributed from any of the accounts listed above at any time.
(3)The balance remaining in all of the accounts listed above shall be sent by check to the Executor(s).
© 2016 Synchrony Bank
D-ESTATEDISTFORM
[REV. 01/2016]
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SIGNATURE
x
Executor Signature
Print Name
x
Executor Signature
Print Name
NOTARY ACKNOWLEDGMENT
State of :
County of
:
Sworn to and acknowledged before me,
day of
, by the Executor(s) named above on this
(Notary)
, 20
.
(Notary signature)
My Commission Expires:
D-ESTATEDISTFORM
[REV. 01/2016]
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