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Courtesy Pay Extended Coverage Consent Form

Complete this form to enroll in Courtesy Pay Extended Coverage. You can also enroll by calling 865-482-4343, sending us a secure message through digital banking, or completing the printable version of this form found on mymembersfirst.org/odp and providing it to your local branch in person or via mail to: PO Box 6828, Oak Ridge, TN 37830.

Name(Required)
Electing or Revoking Extended Coverage(Required)
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.
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Your savings federally insured by the National Credit Union Administration.
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We do business in accordance with the Federal Fair Housing Law and the Equal Credit Opportunity Act.