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Children's Miracle Network Fund Raising Initiative

Interchange Donation Authorization Form

YES, our credit union wants to participate in the national credit union initiative to raise funds for the hospitals in the Children's Miracle Network. We agree to have PSCU Financial Services act as an agent on our behalf and donate to the Children's Miracle Network - through the Credit Unions for Kids brand - 1% of our credit union's credit and/or debit card interchange revenue collected for the months designated below as reported on the FM-001.

Please direct all questions regarding this authorization form to Merry Pateuk, Director of Public Relations, at (800) 932-7728.

Donate 1% Credit Card Interchange Donate 1% Debit Card Interchange Donate Both Credit and Debit Card Interchange

Donation Months (check all that apply)

December 2007 January 2008 February 2008 March 2008

No , our credit union will be unable to participate.

Credit Union Name:

City: State:

Name:

Title:

E-Mail Address