University of Michigan Credit Union 
Visa Classic Credit Card Disclosures and Agreement 

Visa Classic Account Opening Disclosure 

Interest Rates and Interest Charges 

Annual Percentage Rate (APR) 
for Purchases 

11.69% 
This APR will vary with the market based on the Prime Rate. 

APR for Balance Transfers 

11.69% 

This APR will vary with the market based on the Prime Rate. 

APR for Cash Advances 

11.69% 

Penalty APR and When it 
Applies 

Paying Interest 

This APR will vary with the market based on the Prime Rate. 

There is no penalty APR. 

Your due date is at least 27 days after the close of each billing cycle. We will not charge 
you any interest on purchases if you pay your entire statement balance by the due date 
each month. We will begin charging interest on cash advances and balance transfers on 
the transaction date. 

Minimum Interest Charge 

There is no minimum interest charge. 

For Credit Card Tips from the 
Federal Reserve Board 

To learn more about factors to consider when applying for or using a credit card, visit the 
website of the Federal Reserve Board at http://www.federalreserve.gov/creditcard. 

Fees 

Set-up and Maintenance Fees 

•  Annual Fee 

None 

Transaction Fees 

•  Balance Transfer 
•  Cash Advance 
•  Foreign Transaction 

Penalty Fees 

•  Late Payment 
•  Over-the-Credit Limit 
•  Returned Payment 

Other Fees 

No charge for balance transfers. 
Either $2.00 or 2% of each cash advance, whichever is greater (maximum fee: $10). 
Currency conversion: 1% of each transaction. 
U.S. dollar purchases from non-U.S. merchants: 0.8% of each transaction. 

Up to $35.00 
None 
Up to $35.00 

•  Replacement Card 
•  Sales Draft Copy 
•  Statement Copy 
•  Account Research 
•  Expedited Card to Branch 
•  Special Issue Card 
•  Expedited Phone Payment 

$5.00 for each card 
$10.00 
$2.00 
$15.00 per hour 
$15.00 (Same day branch pick up) 
$15.00 (Authorized signer card) 
$3.00 

How We Will Calculate Your Balance:  We use a method called “average daily balance (including new purchases).”  See 
your account agreement for more details. 

Billing Rights:  Information on your rights to dispute transactions and how to exercise those rights is provided in your 
account agreement. 

Prime Rate means the prime rate published in the Wall Street Journal (WSJ) on the fourth Tuesday of each month prior to 
the beginning of each calendar quarter (if published in a range, the highest number in the range will be used) plus a margin.  
The rate is calculated quarterly by adding the margin applicable to the account to the WSJ Prime Rate, subject to any 
applicable rate limits or floors. 

R 9/10 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
VISA Classic Credit Card Agreement 

In  this  agreement  “you”  and  “your”  mean  or  refer  to  all  persons  who  sign  the 
application for this VISA credit card plan. “Card” means the VISA Classic Credit 
Card  and  any  duplicates and renewals we issue. “Account” means your VISA 
Classic  Credit  Card  line-of-credit  loan  account  with  us.  “We,”  “Us,”  or  “Our” 
means or refers to the University of Michigan Credit Union. This agreement is a 
Truth-In-Lending Disclosure statement as well as a contract. 
SECURITY  INTEREST:  THE  GRANTING  OF  A  SECURITY 
INTEREST IN YOUR SHARES AND DEPOSITS WITH US IS 
A  CONDITION  FOR  YOUR  CREDIT  CARD  ACCOUNT.  BY 
SIGNING  YOUR  CARD,  YOU  GRANT  US  A  CONSENSUAL 
SECURITY  INTEREST  IN  ALL  INDIVIDUAL  AND  JOINT 
ACCOUNTS  YOU  HAVE  WITH  US  NOW  AND  IN  THE 
FUTURE  TO  SECURE  ALL  ADVANCES  MADE  UNDER 
YOUR  CREDIT  CARD  AGREEMENT.  WE  MAY,  BUT  DO 
NOT  HAVE  TO,  ALLOW  YOU  TO  WITHDRAW  A  PORTION 
OF  YOUR  SHARES  OR  DEPOSITS  WITHOUT  AFFECTING 
THE  SECURITY  INTEREST.  SHARES  IN  AN  INDIVIDUAL 
RETIREMENT  ACCOUNT  AND  ANY  OTHER  ACCOUNT 
THAT  WOULD  LOSE  SPECIAL  TAX  TREATMENT  UNDER 
STATE AND FEDERAL LAW IF GIVEN AS SECURITY ARE  
NOT  SUBJECT  TO  THE  SECURITY  INTEREST  YOU  HAVE 
GIVEN IN YOUR SHARES.  
  1. ISSUANCE OF CARDS: We will issue VISA credit cards embossed as you 
direct  in  your  application  for  this  plan.  As  soon  as  received,  the  person 
whose  name  is  embossed  on  the  card  must  sign  it  on  the  back.  That 
signature must be in the same form as the name embossed on the front of 
the card. 

  2. USE OF CARDS: You agree not to let someone else use your card. If you 
do, you are agreeing with us that you authorize all use that person makes 
of your card. Therefore, you will be liable for all such use. If you notify us to 
do so, we will take prompt steps to prevent further card use. If you do not 
wish to be bound by this agreement, as soon as you receive your card cut it 
in half and return it to us. You agree that when you or any authorized user 
of your card(s) uses the card to make a purchase or obtain a cash advance 
that the terms of this agreement shall become effective. 

3a.USING THE CARD: To make a purchase or obtain a cash advance, present 
this card to a participating VISA plan merchant, to us or to another financial 
institution, and sign the sales or cash advance draft which will be imprinted 
with  your  card  number.  You  will  receive  a  copy  of  the  draft,  which  you 
should retain to verify your monthly statement. You may not receive a sales 
draft  if  the  transaction  is  less  than  $15.00.  We  will,  upon  request,  furnish 
you  with  a  copy  of  any  draft  over  $15.00  at  a  charge  of  $10.00  per  copy, 
and a copy of any periodic statement at a charge of $2.00 per copy. 

3b.The  VISA  Card  may  not  be  used  for  any  illegal  transaction.  This  includes, 

but is not limited to, illegal Internet gambling. 

3c. CASH ADVANCES FOR CHECKS: If you have signed a Checking Account 
Agreement  which  provides  for  cash  advances  from  your  VISA  loan  plan, 
and we have approved this service, we will process these advances while 
this  agreement  remains  in  effect.  To  be  effective,  all  parties  on  the 
Checking Account must complete the VISA application and be approved. 
3d.  FEES:  Under  this  agreement  you  agree  to  pay  the  fees  listed  below:  All 

fees will be posted to your VISA account. 
  FREE  
Initial Card Fee: 
  FREE  
Second Card: 
$  5.00 
Replacement Card Fee: 
Special Issue Card (authorized signer card): 
$15.00  
Expedited Card to Branch (Same day branch pick up):  $15.00 
$10.00  
Sales Draft Copy: 
$  2.00  
Statement Copy: 
     Up to $35.00  
Returned Payment Fee: 
$15.00 
Account Research/per hour: 
  FREE 
PIN Reissue: 
$  3.00  
Expedited Phone Payment Fee: 
Late Payment Fee: 
     Up to $35.00 
                                                 (payment received on or after 10th of  
                                                          month following payment due date) 

Cash Advance Fee: 

2% of advance 

                                                         (minimum $2.00, maximum $10.00) 

Expedited Card Delivery:          If expedited delivery is required, you agree  

                                                         to pay the cost of any shipping charges. 

4.    AUTOMATIC  TRANSFER  CANCELLATION:  To  cancel  your  automatic 
transfer  payment,  you  must  provide  notice  at  least  5  days  prior  to  the 
scheduled transfer.  

The  Credit  Union  may  cancel  your  automatic  transfer  if  funds  are  not 
available to make the automatic transfer on your payment due date for two 
(2) consecutive months: however you may initiate reinstatement at any time 
as long as the account is current at the time of the reinstatement request. 
5.  PROMISE  TO  REPAY:  You  promise  to  repay  us  for  all  credit  extended 
pursuant  to  authorized  use  of  the  card,  plus  interest  charges  and  other 
charges as provided in this agreement. If two persons sign the application 
for this loan plan, each of you is liable, separately and jointly with the other, 
to repay all such credit, interest charges and other charges. Your obligation 

to pay the account balance continues even though an agreement, divorce 
decree or other court judgment to which we are not a party may direct you 
or one of the other responsible persons to pay the account. 

6.  CREDIT LIMIT: You will be advised of your credit limit under this plan in the 
notice  of  approval  for  participation  in  this  loan  plan.  Each  payment  you 
make  to  the  account  will  replenish  your  credit  limit  by  the  part  of  that 
payment which is applied to principal. You agree not to use your card(s) so 
as to exceed this credit limit. You must submit an application to us in order 
to increase your credit limit. 

7.  MONTHLY PAYMENT: We will mail you monthly statements of your VISA 
loan account as required by law. Every month you promise to pay at least 
the minimum payment upon receipt of your statement. You are required to 
make a payment every month even if you make a payment greater than the 
minimum  amount  due.  By  separate  agreement  you  may  authorize  us  to 
charge a specified payment amount automatically to your Share Savings or 
Checking  Account  with  us.  You  may  pay  more  frequently,  pay  more  than 
the  minimum  payment,  or  pay  the  total  new  balance  in  full,  and  you  will 
reduce  the  interest  charge  by  doing  so.  The  minimum  payment  will  be 
either (a) 4% of your total new balance, or $25.00, whichever is greater, or 
(b) your total new balance, if it is less than $25.00 plus (c) any portion of the 
minimum payment(s) shown on prior statements which remains unpaid. In 
addition, if at any time your total new balance exceeds your credit limit, you 
agree to immediately pay the excess. 

8.  ALLOCATION OF PAYMENTS: We will apply your payments as follows: 

(a) To all outstanding fees and costs, then 
(b) To total unpaid interest charges, then 
(c) To principal balance 

      If a payment is not sufficient to cover the interest charge already billed on 
your  statement(s),  the  remainder  of  that  interest  charge  will  be  collected 
from later payments and will not be added to the daily balance of purchases 
or cash advances. 

9.  CREDITING OF PAYMENTS: Payments made by 5:00 pm Eastern time at 
the  address  provided  on  the  billing  statement  or  during  regular  business 
hours at our office will be credited as of the date of receipt. 

10. RETURNED  PAYMENTS:  If  your  financial  institution  will  not  honor  your 
check or we must return your check to you because it is not signed, we may 
charge your account a fee of up to $35.00. 

11. IRREGULAR  PAYMENTS:  We  can  accept  late  payments  or  partial 
payments,  or  checks/drafts  and  money  orders  marked  “payment  in  full” 
without losing any of our rights under this agreement. Any communications 
concerning  a  disputed  balance,  including  an  instrument  tendered  as  full 
satisfaction of a debt, must be sent directly to University of Michigan Credit 
Union, ATTENTION: DISPUTED CREDIT CARD PAYOFF DEPARTMENT, 
305 E Eisenhower, Suite 220, Ann Arbor, Michigan 48108. 

12.  ANNUAL  PERCENTAGE  RATE:  The  VISA  Platinum  is  subject  to  a 
periodic 
to  an  ANNUAL 
PERCENTAGE RATE of 11.69%, which is equal to the Prime Rate plus 
5.99% [OR 11.69%, whichever is higher]. 

rate  of  0.974%,  which  corresponds 

The  Prime  Rate  is  defined  as  the  Wall  Street  Journal  Published  Prime  (if 
published in a range, the highest number in the range will be used) in effect 
on  the  4th  Tuesday  of  the  month  prior  to  the  beginning  of  each  calendar 
quarter  (“Index”).    Changes  in  the  Index  may  cause  changes  in  the 
ANNUAL PERCENTAGE RATE as of the first day of each calendar quarter 
following  the  Index  Change.  Increases  and  decreases  in  the  ANNUAL 
PERCENTAGE  RATE  will  result  in  like  increases  or  decreases  in  the 
Interest  Charge  you  owe  on  your  Account  and  may  affect  your  minimum 
payment.  This  ANNUAL  PERCENTAGE  RATE  does  not  include  costs 
other than interest. 

13.  PAYING  INTEREST:  Your  due  date  is  27  days  after  your  statement 
closing.  We  will  not  charge  you  any  interest  on  purchases  if  you  pay  the 
entire statement balance in full by the due date each month. We will begin 
charging  interest  on  cash  advances  and  balance  transfers  as  of  the 
transaction posting date. If you fail to pay the entire balance shown on any 
statement within 27 days of the closing date of that statement, we will begin 
charging  interest  on  the  average  daily  balance  from  the  1st  day  of  the 
current billing cycle.  

14.  HOW  WE  WILL  CALCULATE  YOUR  BALANCE  AND  INTEREST:  We 
calculate  your  balance  using  a  method  called  “average  daily  balance 
(including  new  purchases).”  This  balance  is  calculated  by  adding  the 
outstanding  balance  (including  new  purchases  and  deducting  payments 
and  credits)  for  each  day  of  the  billing  cycle,  and  then  dividing  by  the 
number  of  days  in  the  statement  period.  The  daily  balance  is  calculated 
separately for purchases and cash advances.  
The interest charge is calculated using the ANNUAL PERCENTAGE RATE 
currently  in  effect.  The  periodic  daily  rate  is  calculated  by  dividing  the 
ANNUAL  PERCENTAGE  RATE  by  365  days.  The  periodic  daily  rate  is 
then multiplied by the number of days in the statement period and applied 
to the calculated average daily balance.  

15.  RETURNS  AND  ADJUSTMENTS:  If  merchants  who  honor  your  card 
process  a  return  or  adjustment,  they  will  do  so  by  sending  us  a  credit, 
which  we  will  post  to  your  VISA  loan  account,  and  you  agree  to  accept 
returns  or  adjustments  in  this  manner.  You  should  keep  your  copy  of  the 
credit slip to verify the transaction  on your monthly statement. The credits 
posted  to  your  VISA  account  do  not  count  as  monthly  payments.  You are 
required  to  make  at  least  your  minimum  monthly  payment  each  month, 
regardless of whether a credit was posted to your account. However, if your 
credits  and  payments  exceed  the  balance  you  owe  us,  we  will  hold  and 
apply  this  credit  balance  against  future  purchases  and  cash  advances,  a 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
   
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
minimum  payment  would  not  be  due  and,  if  the  amount  is $1.00 or more, 
we will refund it after six (6) months or upon your written request.  

plan.  If  we  cancel,  you  promise  to  return  the  card(s)  to  us.  We  will  notify 
you in writing if we cancel this agreement or reduce your credit limit. 

16.  FOREIGN  TRANSACTIONS:  The  exchange  rate  between  the  transaction 
currency  and  the  billing  currency  used  for  processing  international 
transactions is a rate selected by VISA from the range of rates available in 
wholesale  currency  markets  for  the  applicable  central  processing  date, 
which rate may vary from the rate VISA itself receives, or the government-
mandated rate in effect for the applicable central processing date, plus 1%.  
Transactions made with the Card(s) in US dollars with merchants located in 
foreign countries will be assessed an International Service Assessment fee 
of .8% of the transaction amount. 

17. LOSS  OR  THEFT  OF  CARD:  You  agree  to  notify  us  immediately  upon 

discovering that your card has been lost or stolen. Phone us at:  
1-800-968-UMCU  (toll  free  number)  or  (734)  662-8200  during  regular 
business  hours  Monday  through  Friday.  If  you  can’t  get  an  answer  at  our 
phone numbers, you may call: 1-800-991-4965.  
To  have  a  replacement  card  issued,  write  us  at:  University  of  Michigan 
Credit Union, P.O. Box 7850, Ann Arbor, MI  48107  
You will be charged and you agree to pay $5.00 for each replacement card.   

18. DEFAULT: Your account shall be in default if any of the following things 
occur: (a) you do not make any payment or perform any obligation under 
this agreement that you have with the Credit Union; or (b) you have made a 
false or misleading statement in your credit application and/or in your 
representations to the Credit Union while you owe money on this loan; or 
(c) you should die, or be involved in any bankruptcy, insolvency, 
receivership or custodial proceeding brought by or against you; or (d) a 
judgment or tax lien should be filed against you or any attachment or 
garnishment should be issued against any of your property or rights, 
specifically including anyone starting an action or proceeding to seize any 
of your funds on deposit with the Credit Union;  and/or (e) the Credit Union 
should, in good faith, believe your ability to repay your indebtedness 
hereunder is or soon will be impaired, time being of the very essence. Upon 
any occurrence of Default, and to the extent permitted by law, the entire 
balance of your account shall be immediately due and payable, without 
prior notice or demand, and you understand that interest will continue to 
accrue at the ANNUAL PERCENTAGE RATE shown on the reverse side. If 
the entire balance is not paid immediately upon Default, the Credit Union 
may take whatever actions are permitted by law. 

 19.  CREDIT  INFORMATION:  You  authorize  us  to  investigate  your  credit 
standing  when  opening,  renewing  or  reviewing  your  account,  and  you 
authorize  us  to  disclose  information  regarding  our  credit  experience  with 
you under this loan plan to credit bureaus and other creditors. As may be 
required  by  law  you  are  hereby  notified  that  a  negative  credit  report 
affecting your credit record may be submitted to a credit reporting agency if 
you fail to fulfill the terms of your credit obligation. 

20.  AMENDMENTS:  From  time  to  time,  we  may  amend  this  agreement  by 
giving you written notice of the amendment at least 45 days before it goes 
into  effect,  unless  a  shorter  notice  period  is  permitted  by  law.  The  notice 
will be sent to your last known address appearing in our records when it is 
sent,  and  will  state  the  date  upon  which  the  amendment  will  become 
effective.  Amendments  to  the  ANNUAL  PERCENTAGE  RATE  or  to  any 
other fees or terms to this agreement may be announced in our newsletter, 
MemberGuide. Your use of the card thereafter will indicate your agreement 
to the amendments. To the extent the law permits, and we indicate in our 
notice, amendments will apply to your existing account balance as well as 
to future transactions. 

21.  EFFECT  OF  AGREEMENT:  This  agreement  contains  our  complete 
contract  relating  to this loan plan  and applies to every transaction relating 
to it even though a sales or cash advance draft you sign or a credit or other 
slip may contain different terms. 

If  automated 

22.  ELECTRONIC  ADVANCES  OR  PURCHASES: 

teller 
machines  or  other  electronic  devices  are  available  while  this  agreement 
remains in effect which make it possible for you to obtain a cash advance 
by  use  of  your  card  in  such  a  machine,  or  to  make  a  purchase  from  a 
merchant  that  uses  the  card  in  an  electronic  terminal  that  accesses  the 
VISA  system,  we  will 
furnish  you  with  a  secret  PERSONAL 
IDENTIFICATION NUMBER (PIN). You agree to keep the PIN secret. You 
also  agree  that  you  won’t  write  the  PIN  on  the  card  or  anything  you  keep 
with  the  card.  Your  use  of  the  PIN,  together  with  your  card,  in  getting  a 
cash advance or making a purchase is agreed to constitute your signature 
for purposes of such transaction. 

23.  PLAN  MERCHANT  DISPUTES:  We  are  not  responsible  for  the  refusal of 
any merchant or financial institution to honor your card. Except as provided 
in  “Your  Billing  Rights”  at  the  end  of  this  agreement,  you  promise  to  pay 
what  you  owe  us  under  this  loan  plan  even  if  you  have  a  dispute  with  a 
merchant who honored your card. 

24. RENEWAL: Cards are issued with an expiration date and are renewed for 
a  pre-determined  period.  We  have  the  right,  on  written  notice,  not  to 
renew your card for any reason. 

25. CHANGE OF ADDRESS: If you move, you agree to notify us of your new 
address  in  writing.  Otherwise  we  may  send  monthly  periodic  statements 
and other notices to you at the address shown for you in our records. On a 
joint  account,  we  will  send  statements  and  notices  to  only  one  of  you. 
Unless  we  notify  you  otherwise,  you  agree  to  send  notices  to  us  at  P.O. 
Box 7850, Ann Arbor, Michigan 48107. 

26.  CANCELLATION:  The  cards  are  our  property.  You  may  cancel  this 
agreement at any time by giving us written notice and returning the card(s) 
cut in half to us. We can reduce your credit limit or cancel this agreement 
for  good  cause,  including  your  breach  of  this  agreement,  or  our  adverse 
redetermination of your creditworthiness. Cancellation by you or by us does 
not change your obligation to pay us what you then owe us under this loan 

27.  RESTRICTION  OF  CREDIT  UNION  SERVICES:  If  this  loan  plan  or  any 
other loans that you have with us are past due, credit union services may 
be restricted.  

28. DELAY IN ENFORCEMENT: We can delay enforcing our rights under this 

agreement without losing them. 

29. We reserve the right to block transactions from certain merchants due to a 

high incidence of fraud from that merchant. You can obtain a list of affected 
merchants by contacting us. 

The  laws  of  the  State  of  Michigan  govern  this  agreement,  except  to  the 
extent that federal law controls.     

YOUR BILLING RIGHTS:  Keep this Document for Future Use 
This notice informs you about your rights and responsibilities under the 
Fair Credit Billing Act. 
What To Do If You Find A Mistake On Your Statement 
If you think there is an error on your statement, write to us at:  

Credit Card Department  
P.O. Box 7850 
Ann Arbor, MI 48107 

In your letter, give us the following information: 

•  Account information: Your name and account number.   
•  Dollar Amount: The dollar amount of the suspected error.  
•  Description of Problem: If you think there is an error on your bill, describe 

what you believe is wrong and why you believe it is a mistake. 

You must contact us: 

•  Within 60 days after the error appeared on your statement. 
•  At least 3 business days before an automated payment is scheduled, if 

you want to stop payment on the amount you think is wrong. 

You must notify us of any potential errors in writing.  If you call us, we are not 
required to investigate any potential errors and you may be required to pay the 
amount in question. 
What Will Happen After We Receive Your Letter 
When we receive your letter, we must do two things: 

(1)  Within 30 days after receiving your letter, we must tell you that we 

received your letter. We will also tell you if we have already corrected 
the error. 

(2)  Within 90 days of receiving your letter, we must either correct the error 

or explain to you why we believe the bill is correct. 
While we investigate whether or not there has been an error: 

•  We cannot try to collect the amount in question, or report you as 

delinquent on that amount. 

•  The charge in question may remain on your statement, and we may 

continue to charge you interest on that amount. 

•  While you do not have to pay the amount in question, you are 

responsible for the remainder of your balance. 

•  We can apply any unpaid amount against your credit limit. 
After we finish our investigation, one of two things will happen: 

•  If we made a mistake:  You will not have to pay the amount in question 

or any interest or other fees related to that amount. 

•  If we do not believe there was a mistake:  You will have to pay the 

amount in questions, along with applicable interest and fees.  We will 
send you a statement of the amount you owe and the date payment is 
due.  We may then report you as delinquent if you do not pay the amount 
we think you owe. 

If you receive our explanation but still believe your bill is wrong, you must write 
to us within 10 days telling us that you still refuse to pay. If you do so, we 
cannot report you as delinquent without also reporting that you are questioning 
your bill. We must tell you the name of anyone to whom we reported you as 
delinquent, and we must let those organizations know when the matter has 
been settled between us. 
If we do not follow all of the rules above, you do not have to pay the first $50.00 
of the amount in question, even if your bill is correct. 
Your Rights If You Are Dissatisfied With Your Credit Card Purchases 
If you are dissatisfied with the goods or services that you have purchased with 
your credit card and you have tried in good faith to correct the problem with the 
merchant, you may have the right not to pay the remaining amount due on the 
purchase. 
To use this right, all of the following must be true: 

1.  The purchase must have been made in your home state or within 
100 miles of your current mailing address, and the purchase price 
must have been more than $50.  (Note: Neither of these are 
necessary if your purchase was based on an advertisement we 
mailed to you, or if we own the company that sold you the goods or 
services.) 

2.  You must have used your credit card for the purchase.  Purchases 
made with cash advances from an ATM or with a check that 
accesses your credit card account do not qualify. 
3.  You must not yet have fully paid for the purchase. 

If all of the criteria above are met and you are still dissatisfied with the 
purchase, contact us in writing at: 

Credit Card Department  
P.O. Box 7850 
Ann Arbor, MI 48107 

While we investigate, the same rules apply to the disputed amount as 
discussed above.  After we finish our investigation, we will tell you our decision.  
At that point, if we think you owe an amount and you do not pay, we may report 
you as delinquent. 

Form 820 (9/10)