PAY TO THEORDER OF

MEMO

ROSENORT CREDIT UNION LIMITEDBOX 339ROSENORT, MB R0G 1W0

100 DOLLARS

$

D D M M Y Y Y Y

D D M M Y Y Y Y

VOID

To: Whom it may concern

Re: Void Cheque

Please accept this copy of a void cheque as a confirmation of ____________________ 's bank account information or for the purposes of pre-authorized debit or credit.

Member Signature/CU Stamp

Date

10157 - 879 -

RCU Void Cheque/Pre-Authorization Form