Automatic Transfer

Member Name:_____________________________________________

Account Number:___________________________________________

From Account:
Checking       Basic Membership Savings
Payroll Plus Savings      Other ___________________________

To Account:
Loan ______________________      Basic Membership Savings
Payroll Plus Savings      Other ___________________________

Amount $:_________________________

Frequency:
Monthly
On Specific Calendar Date_______________________________
Weekly, etc.

Additional Instructions:
_______________________________________________________

_______________________________________________________

Date of First Transfer:______________________________________

Member Signature:________________________________________

Date:__________________________________________________

Mail completed form to: Mid American Credit Union 8404 West Kellogg Drive Wichita, Kansas 67209