Holiday Skip-A-Pay Request

Primary Member Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone Number

(###)

###

####

Do you give us permission to call/email or text you regarding your Skip Pay Request? *

Yes

No

How do you prefer to be contacted? *

Email

Phone Call

Text

Select One Month to Skip *

Select one month's payment(s)

November

December

I hereby authorize AlliedFCU to transfer the $30.00 fee (per loan from): *

Select One

Checking

Savings

Other AlliedFCU account

By selecting this box, I acknowledge that I have read and understand the Skip Payment Acknowledgement, Terms and Conditions. *

I agree

Today's Date *

MM

DD

YYYY