Truth in Lending Form

ACCOUNT INFO

EXPLANATION OF LATE CHARGES AND FINANCE CHARGES

LATE CHARGES: 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 assesses is that maximum, 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 Indian which is $17.50, Minnesota which is $0.50 maximum, and Montana which is zero. In IN, if the minimum payment is received within 10days 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 0 .66% in Kentucky - .83% in Missouri) per month.

(An ANNUAL PERCENTAGE RATE of 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 CHARGE is computed by the periodic rate shown above. There is a $1.00 minimum FINANCE CHARGE ($0.50 minimum in Minnesota and Indiana).

YOUR BILLING RIGHTS UNDER THE FIAR 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 name and account number.
• The dollar amount of the suspected error.
• Describe the error and explain, if you can, why you believe there is an error. If you need more information, describe the item you are not sure about.

YOUR RIGHTS AND OUR RESPONSIBILITIES AFTER WE RECEIVED YOUR WRITTEN NOTICE

• We must acknowledge your letter within 30 days, unless we have corrected the error by then. Within 90 days, we must either correct or explain why we believe the error was correct.
• After we receive your later, we cannot try to collect any amount you question, or report you as delinquent. We can continue to bill you for the amount in question, including finance charge and we can apply amount against your credit limit. You do not have to pay any questioned amount while we are investigating, but you are obliged to pay the parts of your bill that are not in questions.
• If we find that we made a mistake on your bill, you will not have to pay any finance charges related to any questioned amount. If we didn’t make a mistake, you may have to pay finance charges, and you will have to make up any missed payments on the questioned amount. In either case, we will send you a statement of the amount you owe and the date that it is due.
• If you fail to pay the amount that we think you owe, we may report you as delinquent. However, if our explanation does not satisfy you and you write to us within 10 days telling us that you still refuse to pay, we must tell anyone we report you to that you have a question about your bill. And we must tell you the name of anyone we reported you to. When the matter is finally settled between us, we must tell anyone we report you to that it has been settled.
• If we don’t follow these rules, we can’t collect the first $50.00 of the questioned amount even if your bill was correct.
• Your continued use of this account constitutes your acceptance of the above stated conditions.

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.

Magical Smiles Family Dentistry
Dental Entity Name

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

A photocopy of this document may act as an original