Scholarship Contribution Form

Here’s my Scholarship Fund contribution

[ ] 1. My check/money order paid to “WSFCU” with “Scholarship Fund” on the memo

[ ] 2. I authorize Women's Southwest FCU to make a one-time transfer from my WSFCU

share account #_____________________

[]25% []50% []100% of my dividends for the quarter(s) that ended on:

[ ]3/31/___ [ ]6/30/____ [ ] 9/30/____ [ ] 12/31/____ through

[ ]3/31/___ [ ]6/30/____ [ ] 9/30/____ [ ] 12/31/____

[ ] 3. I authorize Women's Southwest FCU to transfer from my WSFCU

share account #________________

[]25% []50% []100% of my dividends every quarter beginning with the

quarter that ends/will end on:

[ ]3/31/___ [ ]6/30/____ [ ] 9/30/____ [ ] 12/31/___

until I give you further written notice

Sign Here X_____________________________________________

Return this form to Women's Southwest FCU. Scan it into an attachment to an

e-mail to: WSFCUDallas@sbcglobal.net or fax it to (214) 887-0099 or print out

and mail to: attn: Scholarship Contributions

Women's Southwest FCU

PO Box 720207

Dallas TX 75372

Questions? E-mail us or call (214) 887-0700.