RELEASE FOR INSURANCE PAYMENT
RELEASE AND AUTHORIZATION FOR INSURANCE PAYMENT

I (name) _____________________________request and authorize
(Company name) _______________________________to reimburse:

HOPE BEFORE HEAVEN INC.
P.O. BOX 2002
NEW MARKET STATION
NIAGARA FALLS, NY 14301

PHONE 716-236-7346             FAX 716-236-7137


Policy # _________________

Policy holder’s signature _______________________________Date__/__/__


Witness (Print) __________________________________

Signature _______________________________________


Date__/__/__

NOTARY: State of ______________________; Country of _______________;

On this _____________day of ______________,20___ before me

Appeared_____________________________


Who is known to be the person named herein and who voluntarily execute this release.


Notary signature____________________________

Date commission expires______________________