ACCOUNT INFO
ACCOUNT NAME _______________________

ADDRESS ______________________________
______________________________________

TRUTH IN LENDING

EXPLANATION OF LATE CHARGES AND FINANCE CHARGES

LATE CHARGE: If your minimum payment is not received by the due date, you may be assessed a late payment charge. The amount of the late charge to be assessed is that maximum amount authorized under the laws of the state of your domicile. In most states, the late charge will be $5.00 or 5% of the past due minimum payment, whichever is greater, with a maximum of $20.00, excluding Indiana which is $17.50, Minnesota which is 50Ę minimum or $5.00 maximum, and Montana which is zero. In IN, if the minimum payment is received within 10 days after the due date the late charge will be waived.

FINANCE CHARGE: A FINANCE CHARGE is imposed on those charges not paid in full within 30/60/90/120 days of the date you were first billed for the charges. The balance on which any FINANCE CHARGE is computed is determined by totaling the charges not paid within the time period shown on the front of your billing statement.

The FINANCE CHARGE is a periodic rate of 1.25% (1% in Washington - .58% in Michigan - .66% in Kentucky - .83% in Missouri) per month. (An ANNUAL PERCENTAGE RATEof 15% (- 12% in Washington - 7% in Michigan - 8% in Kentucky - 10% in Missouri)). The FINANCE CHARGE is computed by multiplying the balance on which the FINANCE CHARGEis computed by the periodic rate shown above. There is a $1.00 minimum FINANCE CHARGE (50Ę minimum in Minnesota and Indiana).

YOUR BILLING RIGHTS UNDER THE FAIR CREDIT BILLING ACT

If you think you have been billed incorrectly, or if you need more information about a transaction on your bill, write to us on a separate sheet at First Pacific Corporation, PO Box 3000, Salem, OR 97302. We must hear from you no later than 60 days after we have sent you the first bill on which the error or problem appeared. You may telephone us at 1-800-574-7064, but doing so will not preserve your rights.

In your letter, please include the following information:

YOUR RIGHTS AND OUR RESPONSIBILITIES AFTER WE RECEIVE YOUR WRITTEN NOTICE


I agree to be responsible for all charges for dental services and material not paid by my dental benefits plan, unless the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted under applicable law, I authorize release of any information relating to any insurance claims. I hereby authorize payment of the dental benefits otherwise payable to me directly to the below named dental entity.

Joyful Dental Care                                                                       
Dental Entity Name

Name of Insured (Printed): Signature of insured: ___________________________________                 Date:
Your signature will be required.