Adult Program Pilot

AUTHORIZATION TO RELEASE ACCOUNT INFORMATION

Banco Popular North America (the “Bank”) is partnering with the New York City Office of Financial Empowerment (“OFE”) and the Center for Financial Security (“CFS”) in a study being conducted to determine how to develop better financial programs to assist you and your community.

You may have been asked to participate in the study; if you have agreed to participate you have already been provided information regarding the nature of the study and the fact that your participation in the study is voluntary.

To assist in information-gathering for the study, OFE has asked that the Bank provide certain information relating to your account at the Bank. Prior to the Bank releasing any such information, your written consent is required. Please be assured that your account information shall be used by OFE solely for purposes of the study and not for any marketing or other purposes.

Please confirm your authorization for the Bank to release the following account information to OFE by affirmatively consenting below:

INFORMATION TO BE RELEASED

1. Customer Name

2. Customer Address

3. Date of Account Opening

4. Average Monthly Account Balance

5. Number of Monthly Transactions

6. Use of Bill Pay

7. Use of Direct Deposit

8. Number of Returned Checks

I/We authorize Banco Popular North America to release the above-referenced information to the New York City Office of Financial Empowerment and the Center for Financial Security.

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Account Holder(s) Signature

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Date