Visa Auto-Pay Application

This form may be used by existing members with a RVCU Visa Credit Card to authorize automatic payments on their Visa account. The application must be completed, signed, and mailed or faxed to RVCU.

Member Name ___________________________________________________

Account Number _____________
o Savings
o Checking

VISA Card # 4___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Request is:
o New
o Change
o Cancel

The monthly payment to be deducted from my account is:
o The minimum required payment amount.
o The total amount due.
o A fixed amount greater than the minimum $_________.
o A fixed percentage greater than the minimum _______%.

By signing below, I authorize Roanoke Valley CU to initiate periodic withdrawals from the account indicated for payment on my VISA credit card. I understand that in order for said payment to be processed as requested, funds must be available in the account no later than close of business on the first day of each month. Failure to have sufficient funds available for the withdrawal will result in an insufficient funds fee as described in the Share Account Disclosure. I further understand that Roanoke Valley CU shall be fully protected in honoring the withdrawal and will be under no liability whatsoever should the withdrawal be dishonored with cause.

This authority is to remain in force until Roanoke Valley CU has received written notification from me of its change or termination. To allow Roanoke Valley CU reasonable time to make necessary changes, the notification must be received at least 15 days before the scheduled payment date.

Signature ____________________________________ Date ______________

Mail to:
Roanoke Valley CU
Attn: Member Service
P. O. Box 13045
Roanoke, VA 24030

or Fax to:
(540) 982-3937