Easy Pay Sign-Up Form

VYSTAR CREDIT UNION EASY PAY SIGN-UP FORM

Fill in Full Name of Cardholder

Day Time Phone Number (include area code)

I would like to SIGN-UP to have VyStar Credit Union automatically make my credit card payment each month. Your payment will be applied to your credit card account on the due date and deducted from your checking or savings account two days later.

Please initiate withdrawals from my: (select one)

VyStar Checking Account

VyStar Savings Account

I would like my payment to be applied to my: (one credit card per application):

Visa Classic Visa Gold Visa Savings Secured Platinum Visa Platinum Rewards Plus Platinum Rewards Visa
Platinum Cash Back Business Platinum Rewards Business Secured Platinum Micro Business Platinum

Credit Card #

Select one of the following monthly payment options:

Deduct the minimum payment of $10 or 2% of the unpaid balance, whichever is greater.
Deduct the total unpaid balance each month.
Deduct this fixed dollar amount (must be greater than the minimum scheduled payment): $

I would like to CHANGE my existing Easy Pay Agreement: (select one of the following monthly payment options)

Credit Card #

Deduct the minimum payment of $10 or 2% of the unpaid balance, whichever is greater.

Deduct the total unpaid balance each month.

Deduct this fixed dollar amount (must be greater than the minimum scheduled payment): $

Change automatic payment deduction account to:

I would like to CANCEL my Easy Pay Agreement. I understand that my payment will not be automatically deducted from my account and I will be responsible for making my credit card payment. Cancellation is effective immediately.

Credit Card #

Automatic Payment Deduction Information: Once VyStar receives your application your first Easy Pay deduction will be made from your checking account the very next month. (Example: if your Easy Pay Application is received by VyStar in July, then your first deduction from your VyStar account will occur in August.) Once Easy Pay goes into effect, any additional payments you make will not stop regular monthly Easy Pay deductions. Any changes made on Easy Pay after the initial set-up will not go into effect until the next billing cycle.

E A S Y P A Y A G R E E M E N T

I understand and agree that in order for the Credit Union to make any payments requested in this authorization, I will be responsible for making sure there are sufficient funds in my account by the end of the payment date as indicated on my credit card statement. If a payment is returned due to insufficient funds, a $28 returned payment fee will be charged to my credit card account in addition to a $32 insufficient funds fee. Two consecutive payment attempts, which are returned due to insufficient funds, will result in the termination of this agreement.

I further understand that limitations and fees may apply to certain accounts in accordance with the Credit Union's fee schedule and Federal or State regulations.

I agree that your rights in respect to each withdrawal shall be the same as if it were a check drawn on my account and you should be fully protected in honoring such a withdrawal.

I further agree that if any such withdrawal is dishonored with cause, the Credit Union shall be under no liability, whatsoever, if such dishonor results in late charges or revocation of my card.

This authority is to remain in full force and effective until the Credit Union has received written notification from me of any change in payment or termination in such time and in such manner as to afford the Credit Union a reasonable opportunity to act on it.

I have read and understand the terms of my Easy Pay Agreement. I do not accept the agreement.

_______________________________________________________________________
Cardholder's Signature

___________________________________
Date

Complete the Easy Pay Sign Up Form and return it to:

Credit Card Department
VyStar Credit Union
P.O. Box 45085
Jacksonville, FL 32232-5085

Or, drop it by any VyStar Branch
Or, fax it to (904) 908-2272, Attn: Credit Card Department

Monitor your transactions through VyStar's Internet Banking at www.vystarcu.org or Magic*Touch audio response telephone service at 777-6001 or 800-235-6289.