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							                    KaiPerm Summer
                     Skip-a-Payment
Member
Name_____________________Account#____________________
I wish to skip an eligible* loan payment(s) for loan
number(s)____________

a). For the month of:                 June 2011               July 2011                August 2011

b). For the following pay dates (must be only 2 consecutive) :
          June 3, 2011                       July 1, 2011                      Aug 12, 2011
          June 17, 2011                      July 15, 2011                     Aug 26, 2011
                                             July 29, 2011
I/We authorize the Credit Union to extend my/our loan payment(s) as requested
above. I/We understand that this adjustment will increase the time it takes to
repay my/our loan(s). In addition, I/We understand that interest continues to
accrue against the unpaid balance. If the loan is paid with payroll deduction
method, I/We understand the skipped payment(s) will be deposited into the
account listed above. I/We understand the next payment will be due on the next
scheduled date.

 There is a $3.00 donation request per loan which will be donated to our Credit
     Union for Kids Doernbecher fund.
          I authorize you to withdraw the funds from my account.

          I have enclosed a check to cover the cost of the donation.

Member Signature                                                               Date

Joint Owner Signature                                                 Date
 Fax to 503-813-3273 or Interoffice mail to KFCU / KPB-3
*Eligible loans exclude Equity loans, Real Estate loans, and VISA.
 **Your loan must be current and you must have made at least 3 months consecutive
payments on your loan to qualify. The donation is voluntary.
(Office use only)

   Gen/Payment      Transfer file   donation posted   Completed by ___________________ Date____________