CENTRAL VERMONT TEACHERS CREDIT UNION

I, _______________________________________ give ________________________________

(Name) (School System)

permission to: (SELECT ONE)

____Increase my current deduction in the amount of $___________________

____Decrease my current deduction in the amount of $__________________

____Deduct from my salary the amount of $________________

This will occur biweekly/monthly.

____________________________________

(Signature of Employee)

____________________________________

(DATE)

(Central Vermont Teachers Credit Union - telephone: 479-9411)

Please detach here. Give top portion to your payroll clerk. Send the bottom portion to:

Central Vermont Teachers Credit Union

265 So. Main Street

Barre, VT 05641

To the treasurer:

(Select one)

____I am increasing my credit union contribution by $__________________

____I am decreasing my credit union contribution by $__________________

____Please credit my account in the amount of $________________

This amount is to be credited to my account as follows:

SHARES____________________________

LOANS_____________________________

CHRISTMAS CLUB__________________

NAME:_____________________________

SCHOOL:___________________________

DATE:______________________________