Complete if Visa Payment is to be taken from Hiway Federal Credit Union:
I (we) authorize Hiway Federal Credit Union (HFCU) to initiate debit entries to my (our):

• Checking Account #________________
• Savings Account #________________

The amount of the payment for my (our) credit card to be deducted approximately 25 days after the closing of the statement is (check one):

• Minimum payment due
• Balance in full
• Fixed Payment $_____________

Complete if Visa Payment is to be taken from another Financial Institution:
I (we) authorize HFCU and the financial institution named below to initiate debit entries to my (our):

• Checking Account #________________
• Savings Account #________________

The amount of the payment for my (our) credit card to be deducted approximately 25 days after the closing of the statement is (check one):

• Minimum payment due
• Balance in full
• Fixed Payment $_____________

____________________________________________________________________________________
Name and Telephone Number of Financial Institution

____________________________________________________________________________________
Address of Financial Institution including City, State and Zip Code

____________________________________________________________________________________
Bank Routing Number (The first 9 digits on the bottom of your check)

This authority is to remain in full force and effect until I (we) provide HFCU with a written authorization requesting that a change be made or that periodic payments be terminated. I (we) must provide this written authorization as to change or termination so that it is received by HFCU at least 30 days prior to any change or termination requested.

I (we) understand and agree that in order for HFCU to make any payments requested in this Authorization Form, I (we) must have the payment amount available in my (our) account, or my (our) account may be assessed an NSF fee.

I (we) further understand and agree that HFCU shall not be responsible for any act or failure to act on their part, except in the case of gross negligence or willful misconduct. Furthermore, I (we) agree to hold HFCU harmless from any claims, liabilities, attorney's fees, and other costs and expenses of any and every kind and nature which may be incurred by them by reason of their performance under this Authorization Form.

Name: ________________________________________________________________

Joint Name: __________________________________________________________

Visa Account Number ________________________________

Signature: ________________________________ Date: _________________

Joint Signature: ________________________________ Date: _________________

To initiate Automatic Visa Payments, print, sign and return this completed form to -