Partial Death Payment of $5000.00 and Release Agreement

የአባል መታወቂያ ቁጥር/ Member ID Number:   

ኅብረት መረዳጃ ማህበር

Hebret Mutual Aid Society

የሞት ክፍያ ሰነድና የሀላፊነት ማውረጃ ስምምነት

Partial Death Payment of $5000.00 and Release Agreement

የሟች አባል መሉ ስም/Deceased Member’s Full Name፡ ስም / Name             

ከዚህ በላይ ስማቸው የተጠቀሰው የኅብረት መረዳጃ ማህበር እ. ኤ አቆጣጠር            ከዚህ አለም በሞት የተለዩ ሲሆን ከዚህ በታች ስሜ/ስማችን የተጠቀሰው የአባሉ ተወካይ/ተወካዮች በመተዳደሪያ ደንቡ መሰረት የቀብር ስርአት ለማስፈፀሚያ ማህበሩ የሚሰጠውን ቀሪውን $5,000 (አምስት ሺህ ዶላር) ተፈላጊውን መረጃ አቅርቤ መቀበሌን አረጋግጣለሁ/ እናረጋግጣለን። ማህበሩ ገንዘቡን ከመክፈል በስተቀር ቀብሩን የማስፈፀም ምንም አይነት ሀላፊነት የሌለበት መሆኑንና ወደፊትም ገንዘቡ በትክክል ስራ ላይ ባለመዋሉ ለሚነሳ ማንኛውም አይነት ችግር ተጠያቂ አለመሆኑን መስማማቴን/መስማማታችንን አረጋግጣለሁ/እናረጋግጣለን። በተጨማሪም የኅብረት መረዳጃ ማህበር የሟችን ፎቶግራፍ እና መረጃ በድህረገጹ ላይ እንዲለጥፍ የፈቀድኩ/የፈቀድን መሆኑን አረጋግጣለሁ/እናረጋግጣለን። ይህንን የሞት ክፍያ ሰነድና የሃላፊነት ማውረጃ ስምምነት በሙሉ አንብቤና/አንብበን ተረድቼ/ተረድተን በፈቃደኝነት ከዚህ በታች ፈርሜያለሁ/ፈርመናል። Upon the death of the Hebret Mutual Aid Society member mentioned above on               , I/We the undersigned, representative(s) of the deceased, were unable to get the original death certificate to receive the full and final payment the Society gives for funeral expenses as stated in the Bylaw, hereby confirm receipt of the remaining $5,000 upon submission of the original death certificate. I/We acknowledge and agree that The Society is not responsible for funeral arrangements other than paying out the money and will not be held liable for any issue/problem that arises in the future due to the improper disbursement of the funds. In addition, I/we confirm that I/we have given permission to HMAS to post the picture of the deceased member with some basic information on Hebret Mutual Aid Society website. I/we hereby declare that I/we have fully read and understood this Death Payment & Release Agreement and voluntarily signed here below.

1.                                                                                                                                                                             

የተቀዳሚ ተወካይ መሉ ስም/Primary Designee ’s Full Name የተቀዳሚ ተወካይ ፊርማ / Primary Designee’s Signature

አድራሻ/ Address                                             የተወካዮ የመንጃ ፈቃድ ወይንም መታወቂያ Driving License/ Government Id/ Passport              የስልክ ቁጥር / Telephone #               

2.                                                                                                                                                                       

የሁለተኛ ተወካይ መሉ ስም/ Secondary Designee’s Full Name የሁለተኛ ተወካይ ፊርማ /Secondary Designee’s Signature

አድራሻ/ Address                                   

የተወካዮ የመንጃ ፈቃድ ወይንም መታወቂያ Driving License/ Government Id/ Passport           

የስልክ ቁጥር / Telephone #                 

የቦርድ አባል ስም/ Board Member                         ፊርማ/Signature             

የቦርድ አባል ስም/ Board Member                         ፊርማ/Signature              

ቀን / Date   የቼክ ቁጥር / Check Number            

Hebret Mutual Aid Society, Inc–0000 Xxxxxxx Xxx Xxx# 000, Xxxxxx Xxxxxx, XX 00000–Email: Xxxxxx0000@xxxxx.xxx