Member Information Member Name Member Number Phone Number Creditor Information Creditor Name Account Number Amount to Transfer $ Payment Address City State ZIP Code Creditor Information Creditor Name Account Number Amount to Transfer $ Payment Address City State ZIP Code Add More Creditors Creditor Information Creditor Name Account Number Amount to Transfer $ Payment Address City State ZIP Code Creditor Information Creditor Name Account Number Amount to Transfer $ Payment Address City State ZIP Code Electronic Signature I certify that everything I have stated in this Balance Transfer form and on any attachments is correct. By submitting this Balance Transfer form, I authorize Signature Federal Credit Union to advance the requested funds from my Signature FCU Visa credit card to make a payment on, or payoff the account(s) listed above. I understand that for the balance transfer(s) to be processed, I must be a member with Signature FCU in good standing. Signature Date (mm/dd/yyyy) Please enter the security code below