Skip A Payment Request

^* Denotes Required Field

^*Member Full Name:

^*Social Security Number:

^*Phone Number:

^*Email Address:

* I am requesting to skip my loan payment(s):

Loan Number 1:

Loan Number 2:

Loan Number 3:

Processing Fee

I elect to pay the $25.00 processing fee via:

Savings Account #:

Checking Account #:

Cash

Add Fee to Loan

Must be a member in good standing. All loans must be current and have not been past due more than 15 days in the past 6 months. Skip - A - Pay is not offered on Credit Cards, Home Equity lines, 1st or 2nd Mortgages, Lines of Credit or Overdraft accounts. Loan payments made by payroll deduction or ACH will be deposited into your account as normal unless stopped prior to the date.

By checking the box below, you authorize the Credit Union to extend your final payment by one month on each loan designated above. Interest will continue to accrue on your loan(s) during the month that you skip your payment.

If a GAP Waiver insurance policy was purchased at the origination, or during the course of the above-referenced loan, doing any Skip-A-Payment may have an adverse impact as to how a GAP claim is paid by the Gap insurance carrier. The Credit Union will not be liable for any denial of GAP benefits created by Skip-A-Payment products.

I agree to the terms set forth in the Skip-A-Payment agreement.