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:

Skip-A-Payment Month:

Loan Number 2:

Skip-A-Payment Month:

Loan Number 3:

Skip-A-Payment Month:

Processing Fee Per Loan

I elect to pay the $28.00 processing fee per each loan via:

Savings Account #:

Checking Account #:

Cash

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.