Fillable |Account Change Form I/We authorize the Credit Union (City of Oakland)

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|Account Change Form I/We authorize the Credit Union (City of Oakland)

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U.S.A. forms for City of Oakland

BROWSE CITY OF OAKLAND (CA) FORMS

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Revised 6/4/2020
I/We authorize the Credit Union to make and accept the following changes to my/our accounts.
ADD CHANGE REMOVE
Share Draft/Checking
Debit Card
Debit Card Joint Owner
Overdraft Protection Share
Transfer
Joint Owner
Name Change
Beneficiary
Address Change
Other ___________________
OWNERSHIP INFORMATION
Member Name: ____________________________
Street: _____________________________________________ SSN/TIN: _______________________________________________
City/State/Zip: _______________________________________ Driver’s License #: ________________________________________
Home Phone #: ______________________________________ Driver’s License Issued Date ____________ Exp Date ____________
Work Phone #: ________________________________________ Date of Birth: ___________________________________________
Cell Phone #: _________________________________________ Mother’s Maiden Name: ___________________________________
e-mail Address: ________________________________________ Employer: ______________________________________________
Do you have a different mailing address?
Street/PO Box: _____________________________________ City: _________________________ State: _________ Zip: __________
JOINT OWNER/AGENT
The account(s) is a Joint Account with Rights of Survivorship
Joint Owner: If required by the Credit Union, removal of a joint account owner requires consent of all owners, and we will hold the
Credit Union harmless for actions regarding account access. The removed joint account owner(s) relinquish ownership interest including
any membership share in the account(s) set forth in the “ACCOUNT TYPE/SERVICES” section. This relinquishment does not affect my/our
obligation to any loan accounts.
Agent: The Credit Union will not recognize the authority of someone to whom you have given power of attorney without written
authorization and a copy of the Power of Attorney on record at the Credit Union
Joint Owner: ADD CHANGE REMOVE Agent: ADD CHANGE REMOVE
Joint Owner/Agent 1: _________________________________
Street: _____________________________________________ SSN/TIN: _______________________________________________
City/State/Zip: _______________________________________ Driver’s License #: ________________________________________
Home Phone #: ______________________________________ Driver’s License Issued Date ____________ Exp Date ____________
Work Phone #: ________________________________________ Date of Birth: ___________________________________________
Cell Phone #: _________________________________________ Mother’s Maiden Name: ___________________________________
e-mail Address: ________________________________________ Employer: ______________________________________________
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|Account Change Form
SUBSEQUENT ACTIONS
Date:
Member Account #:
Revised 6/4/2020
Joint Owner: ADD CHANGE REMOVE Agent: ADD CHANGE REMOVE
Joint Owner/Agent 2: _________________________________
Street: _____________________________________________ SSN/TIN: _______________________________________________
City/State/Zip: _______________________________________ Driver’s License #: ________________________________________
Home Phone #: ______________________________________ Driver’s License Issued Date ____________ Exp Date ____________
Work Phone #: ________________________________________ Date of Birth: ___________________________________________
Cell Phone #: _________________________________________ Mother’s Maiden Name: ___________________________________
e-mail Address: ________________________________________ Employer: ______________________________________________
ACCOUNT DESIGNATIONS
Payable on Death (POD) Beneficiaries: ADD CHANGE REMOVE
Beneficiary 1/POD Payee: _____________________________ Beneficiary 2/POD Payee: _________________________________
Street: _____________________________________________ Street: _________________________________________________
City/State/Zip: _______________________________________ City/State/Zip: __________________________________________
Date of Birth: ________________________________________ Date of Birth: ___________________________________________
SSN: _______________________________________________ SSN: __________________________________________________
Other Info: _____________________________________________________________________________________________________
AUTHORIZATION
I/We agree that the changes on this Card amend the previously signed Account Card and are subject to the
terms and conditions of the Membership and Account Agreement, Truth-in-Savings Disclosure, Funds Availability
Policy Disclosure, if applicable, and to any amendment the Credit Union makes from time to time which are
incorporated herein. I/We acknowledge receipt of a copy of the agreements and disclosures applicable to the
accounts and services requested. If an access card or EFT service is requested and provided, I/We agree to the
terms of and acknowledge receipt of the Electronic Fund Transfer Agreement and Disclosure.
X
X
Signature Date Signature Date
X
X
Signature Date Signature Date
CREDIT UNION USE ONLY
Primary Beacon Score ____________ Type of Debit Card Approved:
Platinum
Gold
Silver Employee’s Initial ________
Joint Beacon Score ____________ Type of Debit Card Approved:
Platinum
Gold
Silver Employee’s Initial ________
If you are mailing, e-mailing or faxing this Account Change Form, please include a copy
(front and back) of your State or Government issued ID card. Thank you!
Mailing address: 6400 SE Lake Road, Suite 125, Milwaukie, OR 97222
E-mail address: membercare@providencecu.org
Fax number: (503) 513-8770
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Account Change Form IWe authorize the Credit Union (City of Oakland)

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Completed 12 November 2021

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