Membership/Savings Application

* Required Fields

Truth In Savings & Privacy Notice:

I have read and understand the Truth in Savings Policy and Privacy Notice.

Account Type

All of the terms, conditions, form of account ownership, account selection and other information indicated on this Application apply to all of the accounts listed unless the Credit Union is notified in writing of a change.

Type of Account:

Child Share

Account Ownership

Designate the ownership of the accounts and responsibility for the services requested:

Individual

Joint Account with Rights of Survivorship

MEMBER APPLICATION AND OWNERSHIP INFORMATION

Member/Owner:

SSN/TIN:

Date of Birth:

/ /

Street:

City/State/Zip:

Driver's Lic. No:

Mother's Maiden Name:

Best Contact Phone:

Work Phone:

Employer:

Membership Eligibility:

E-Mail:

Joint Owner:

SSN/TIN:

Date of Birth:

/ /

Street:

City/State/Zip:

Driver's Lic. No:

Mother's Maiden Name:

Best Contact Phone:

ACCOUNT DESIGNATIONS

Beneficiary/POD Payee #1:

Street:

City/State/Zip:

Beneficiary/POD Payee #2:

Street:

City/State/Zip:

TIN CERTIFICATION AND BACKUP WITHHOLDING INFORMATION

You have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. Complete a W-8 BEN if you are not a U.S. person. If a W-8 BEN is completed, your signature does not serve to certify this section.

Exempt payee code (if any):

Exemption from FATCA reporting code (if any):

Enter your intials (Primary):

Enter your intials (Joint):

Security Code:

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