Balance Transfer Form - Go Energy Credit Union

Institution Name 1

Payment Address 1

Account Number 1

Amount 1

Institution Name 2

Payment Address 2

Account Number 2

Amount 2

Institution Name 3

Payment Address 3

Account Number 3

Amount 3

Institution Name 4

Payment Address 4

Account Number 4

Amount 4

Institution Name 5

Payment Address 5

Account Number 5

Amount 5

Go Energy Financial is hereby authorized to pay off the balance(s) due on the above revolving charge account(s) by issuing a check to the account indicated and adding a cash advance for the total amounts to my Go Energy Financial VISA Account.

Go Energy Financial VISA Account #

Agreement

I hereby confirm that I will pay said amount, with any charges due thereon, to Go Energy Financial in accordance with the terms of the charge card agreement governing the use of said card.

I understand that the Credit Union is not responsible for my payment being late or lost in the mail. I also understand that there may be outstanding charges on my account and this advance may not pay off the total balance due. I further understand that if there is an insufficient limit on my Credit Union VISA account, that the Credit Union will pay off my accounts in the order listed, and return any account(s) that cannot be paid in full.

Signature Agreement

By submitting this application electronically, I/we agree to the same terms that apply to a signed application. If there is a co-applicant on this loan, that co-applicant has authorized the submission of this application. This electronic submission qualifies as my/our signature.

Signature, please type Name

Date