Please complete the form in full
Member Number *:

Your Name *:

Your Email *:

Your Contact Phone No *:

Your Address *:

Employer Name:*:

Employer Address:*:

Occupation:*:

Time in Employment:*:

Employment Type:*:
—Please choose an option—Public SectorEmployedSelf EmployedOther

Reason for Temporary Arrangement:*:

Acknowledgements
Acknowledgement1:*: I acknowledge that the Credit Union may require and request supporting documentation to fully consider my application, i.e. a Letter from my Employer confirming I have been temporarily laid off from work or/and have suffered a reduction in Income due to Covid-19 or a copy of my last self-assessment return and a brief note from me on the impact on my business (if I am self-employed). I understand that I can send this information to the Credit Union at creditcontrol@fccu.ie.YesNo

Acknowledgement2:*: I understand and acknowledge that the Arrangement is a temporary arrangement which, if approved, commences and ends at the dates that will be specified in writing by First Choice Credit Union. YesNo

Acknowledgement3:*: I understand that the total cost of credit may increase as a result of this COVID-19 Temporary Arrangement. I further understand and acknowledge that my original Credit Agreement will be amended temporarily for the time period that will be specified in writing and will return to my original Credit Agreement on the date this temporary arrangement ends. I understand that it is my responsibility to cancel or stop the payments to my loan account for the duration of the temporary arrangement period. Any funds transferred during the duration of the temporary arrangement period will not be reimbursed to me. YesNo

Acknowledgement4:*: I agree to the TERMS & CONDITIONS. for access to and use of the Credit Union website and web forms and to the Processing of my data, which may include sensitive data, for the purposes of reviewing this application in accordance with the PRIVACY NOTICE.YesNo

What members are eligible under the temporary scheme:
• Members seeking an arrangement given a temporary reduction in income has occurred as a result of the current health crisis and they are not in financial difficulty and/or were not concerned about their ability to meet their repayments prior to COVID-19.
• Members who are currently not in a forbearance arrangement with the Credit Union or if the members have been meeting all the terms and conditions of those arrangements and require a new temporary arrangement due to the impacts of COVID-19.
• Members who were not previously in arrears prior to March 2020 on any account or other CU loan.

Signature *:

Date *:

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