Skip A Payment Authorization COVID-19 Relief Skip-A-Pay Name: First Last Loan Number:Payment(s) to skip: June July Terms:*This request is due to financial hardship caused by COVID-19. I understand that my loan must be in good standing, which means the loan payments are not currently greater than 30 days past due at the time the Skip-A-Pay is received by the bank. By completing the Skip-A-Pay form, I am requesting Highpoint Community Bank to advance the loan due date equal to the number of payments skipped. I agree that the current balance of the loan is extended by the amount of the payment(s) skipped and that interest will continue to accrue on my loan balance throughout the deferred payment period, which may further extend the term of my loan. I understand that any coverage for life and/or disability insurance will remain in effect only up to 90 days past the original term of my loan. If my loan is secured by a vehicle, and I purchased GAP, a deferred payment may leave an unpaid balance on my loan in the event of a GAP claim. To see how many, if any, deferred payments are covered annually by GAP in the event of a loss, please see the exclusions and terms of your GAP Waiver Addendum. I have read and understand the Skip-A-Pay terms.NameThis field is for validation purposes and should be left unchanged.