Receipt, Indemnity, and Refunding Agreement

Receipt, Indemnity, and Refunding Agreement
1. The undersigned First Name* Last Name* is the surviving family member or beneficiary of First Name* Last Name* , a deceased employee of The University of Northern Iowa who died on Date* .
2. The undersigned, as the surviving family member or beneficiary, is the only person entitled to the decedent's estate, including amounts payable to the decedent's estate by The University of Northern Iowa.
3. The undersigned has determined that it unnecessary to commence an administration of the decedent's estate.
4. The undersigned requests The University of Northern Iowa to distribute to the undersigned:
Check Items below as appropriate:

Accrued salary due to the decedent as the time of death.Unpaid sick leave accumulated by the decedent if retirement eligible.Unpaid vacation leave accumulated by the decedent.
The undersigned acknowledges receipt of all of the foregoing checked items from The University of Northern Iowa, less and FICA taxes due thereon, and agrees to hold The University of Northern Iowa, the State of Iowa, and the Board of Regetns, State of Iowa, harmless for any and all claims, including reasonable attorneys fees, against it by reason of such payments, including refunding to The University of Northern Iowa any amounts for which it may be liable by reason of making such payments, not to exceed the aggregate amount of such payments.

The undersigned acknowledges and represents that:

(a) The undersigned has read the foregoing, understands it, and signs it voluntarily;

(b) No oral representations, statements, or inducements, apart from this agreement, have been made to the undersigned;

(c) The undersigned is fully competent;

(d) The undersigned would be the sole beneficiary of the decedent's estate if an estate were opened on behalf of the decedent.

(e) The undersigned executes this agreement for full, adequate and complete consideration fully intending to be bound by the same; and

(f) This agreement shall be binding upon the heirs, successors, assigns, and estate of the undersigned.
Your Name *
First and Last Name
Today's Date*

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Your Address*

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Signature*

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