Fillable Account Form New Member Existing Member (Georgia's Own Credit Union)

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Account Form New Member Existing Member (Georgia's Own Credit Union)

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©CUNA Mutual Group 2008, 10-12, 14 All Rights Reserved DGADY9 (DX1004)-e
Account Form
New Member Existing Member
PRIMARY MEMBER INFORMATION
Member Name
Membe
r
#
Street
Account #
Cit
y
/State/Zi
p
SSN/TIN
Monthl
y
MTG/Rent Pa
y
ment $
Own Rent
Date of Birth
Em
p
lo
y
er Name
Job Title
_______________
_______
Em
p
lo
y
ment Date
Home Phone
Alimony, child support, or separate maintenance income need not be revealed if you do not choose to have it considered.
Em
p
lo
y
ment Income $
e
Other income $ Work Phone
Email Address
Cell Phone
Driver’s License #
State
Issue Date Ex
p
Date
U. S. Citizen U. S. Resident Alien NOT a U. S. Citizen or Resident Alien Mother’s Maiden Name
To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that
identifies each person who opens an account. What this means to you: When you open an account, we may ask for your name, address, date of birth, and other information that will
allow us to identify you. We will ask to see your driver’s license or other identifying documents.
ELIGIBILITY FOR MEMBERSHIP
Employed by Sponsor Group
Resident of
Count
y
Georgia’s Own Foundation Getting Ahead Association Qualified by Family Member
Name
ACCOUNT AND SERVICES
Savings Checking VISA
®
Debit Card Money Market Savings Certificate IRA Other:
(
Additional forms/disclosures re
q
uired
)
JOINT OWNERS
Joint Owne
r
1 Name:
SSN/TIN
Street Date of Birth
Cit
y
/State/Zi
p
Home Phone
Em
p
lo
y
er Name
Job Title Work Phone
Relation to Membe
r
Email Address
Cell Phone
Driver’s License # State Issue Date Ex
p
Date
Joint VISA
®
Debit Card
U. S. Citizen U. S. Resident Alien NOT a U. S. Citizen or Resident Alien
Use this SSN/TIN as Taxpayer Number for the following account(s):
Joint Owne
r
2 Name:
SSN/TIN
Street Date of Birth
Cit
y
/State/Zi
p
Home Phone
Em
p
lo
y
er Name
Job Title Work Phone
Relation to Membe
r
Email Address
Cell Phone
Driver’s License # State Issue Date Ex
p
Date
Joint VISA
®
Debit Card U. S. Citizen U. S. Resident Alien NOT a U. S. Citizen or Resident Alien
Use this SSN/TIN as Taxpayer Number for the following account(s):
Name Change
New Name
Former Name
Remove Joint Owner(s)
Name to remove SSN
List Account #s
Joint Account Owner(s) may only be removed in limited cases of death or upon minors reaching age of majority. Removed joint account owner(s) relinquish
ownership interest including any membership share in the account(s) listed. This relinquishment does not affect obligations on any loan account(s). Removal of
a joint owner does not affect past liabilities on the account. The Credit Union restricts the removal of Joint Owner(s) in all other situations.
©CUNA Mutual Group 2008, 10-12, 14 All Rights Reserved DGADY9 (DX1004)-e
ACCOUNT DESIGNATIONS
Add Beneficiar
y
to existin
g
account Delete Beneficiar
y
Chan
g
e Account Desi
g
nation
Pa
y
able on Death
(
POD
)
Account S
p
ecif
y
Account
(
s
)
:
POD BENEFICIARIES
Beneficiar
y
SSN Beneficiar
y
SSN
Phone Numbe
r
Date of Birth Phone Numbe
r
Date of Birth
Address Address
Address Address
TIN CERTIFICATION AND BACKUP WITHHOLDING INFORMATION
Under penalties of perjury, I certify that:
(1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued), and
(2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified
me that I am no longer subject to backup withholding, and
(3) I am a U.S. citizen or other U.S. person. For federal tax purposes, you are considered a U.S. person if you are: an individual who is a U.S.
citizen or U.S. resident alien; a partnership, corporation, company, or association created or organized in the United States or under the laws of the
United States; an estate (other than a foreign estate); or a domestic trust (as defined in Regulations section 301.7701.7).
(4) The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification Instructions: Cross out item 2 above if 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) ________________
SIGNATURES
BY SIGNING BELOW, YOU AUTHORIZE GEORGIA’S OWN CREDIT UNION TO
DELIVER OR CAUSE TO BE DELIVERED TO YOU AT THE TELEPHONE NUMBERS
PROVIDED ABOVE, ADVERTISING AND TELEMARKETING CALLS AND TEXT
MESSAGES USING AN AUTOMATIC TELEPHONE DIALING SYSTEM AND/OR AN
ARTIFICIAL OR PRERECORDED VOICE. YOU ARE NOT REQUIRED TO SIGN THIS
AUTHORIZATION (EITHER DIRECTLY OR INDIRECTLY), OR AGREE TO ENTER
INTO THIS AGREEMENT AS A CONDITION OF PURCHASING ANY PROPERTY,
GOODS OR SERVICE (INCLUDING A LOAN). You may withdraw the consent set forth
herein by written notice to us at P.O. Box 105205 Atlanta, GA, 30348, via phone at
800-533-2062 or by any other reasonable means.
X
Signature (Member) Date
X
Signature (Joint Owner 1) Date
X
Signature (Joint Owner 2) Date
1. You promise that everything you have stated on this Account Form or provided
verbally to us in connection with this application is correct. You authorize the Credit Union
to check your employment and credit history and to obtain credit reports in connection
with your request for membership. You authorize the Credit Union to use your credit
reports for marketing purposes, including but not limited to loan pre-approvals, and in
considering whether to offer you other credit and services. You understand the Credit
Union will rely on the information on this application and in your credit reports to make its
decision. If there are any important changes you will notify us in writing immediately. You
also agree to notify us of any changes in your name, address or employment within a
reasonable time thereafter.
2. By signing or otherwise authenticating, I/we agree to the terms and conditions of
the Membership and Account Agreement, Truth-in-Savings Disclosures, Privacy
Disclosure, Electronic Fund Transfer Agreement and Disclosure, Funds Availability Policy
Disclosure, if applicable, and to any amendment the Credit Union makes from time to time
which are incorporated herein. Your signature below means (1) that you agree to the
terms and conditions of the disclosures/agreements that apply to any EFT service,
savings account, checking account, or savings certificate account you have requested in this
application and which you obtain from us and (2) that the Membership Account Agreement and
the Electronic Fund Transfers Agreement and Disclosures are all intended to be instruments
under seal.
3. By signing below you acknowledge and agree that any updates identified herein amend
the previously signed Account Form(s), and are subject to the terms and conditions of the
applicable disclosures noted above.
4. By executing this Account Form you agree we and our third-party debt collectors may
contact you by telephone or text message at any telephone number associated with your
account, including wireless telephone numbers (i.e., cell phone numbers) which could result in
charges to you, in order to service your account or collect any amounts owed to us, excluding
any contacts for telemarketing purposes as prescribed by law. You further agree methods of
contact may include use of pre-recorded or artificial voice messages, and/or use of an
automatic dialing device. You may withdraw the consent to be contacted on your cellular
device by written notice to us at P.O. Box 105205 Atlanta, GA, 30348, by email to
DoNotCallMyCell@georgiasown.org, via phone at 800-533-2062 or by any other reasonable
means. If you have provided a wireless telephone number (cell phone number) on or in
connection with this application, you represent and agree you are the wireless (cell phone)
subscriber with respect to the wireless telephone number (cell phone number) provided. You
represent and agree further you are and will be the wireless telephone (cell phone) subscriber
with respect to each wireless telephone number (cell phone number) provided by you to the
Credit Union.
5. The Internal Revenue Service does not require your consent to any provision of
the document other than the certifications required to avoid backup withholding.
X
Signature (Member) Date
X
Signature (Joint Owner 1) Date
X
Signature (Joint Owner 2) Date
Credit Union Use Only
Date
O
p
ened b
y
Checked Identification
Other Identification Information:
Credit Report/OFAC Member Services Guide TIS TCPA Verafin Reg E Opt In
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Account Form New Member Existing Member (Georgia's Own Credit Union)

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Completed 23 December 2020

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