Account Information Update Form
1440 Rosecrans Avenue, Manhattan Beach, CA 90266
800.854.9846 | kinecta.org
KFCUR23494-05/19
SECTION 1
PLEASE COMPLETE THE APPLICABLE SECTIONS ONLY
MEMBER NAME (FIRST, MIDDLE INITIAL, LAST) JR. / SR. MEMBER NUMBER
SECTION 2
ADDRESS / PHONE / EMAIL
Proof of residence is required when changing the address on an account that has been opened less than 30 days. Acceptable documentation includes: current utility bill (electric bill, water bill, natural gas
bill, home landline telephone bill, cable/satellite bill), vehicle registration, etc.
RESIDENCE ADDRESS CITY STATE ZIP
MAILING ADDRESS CITY STATE ZIP
HOME PHONE NUMBER CELL PHONE NUMBER WORK PHONE NUMBER
MOTHER’S MAIDEN NAME DATE OF BIRTH EMAIL ADDRESS
EMPLOYER OCCUPATION
SECTION 3
NAME CHANGE ONLY**
(Order the following in new name, check all that apply) £ Debit Card £ Checks £ MasterCard Credit Card
**For Name Changes, supporting documentation showing the new name is required [i.e. legible copy of State or Government issued identification (Driver’s License, ID, U.S. Passport) Marriage
Certificate, or Divorce Decree]. If providing a Marriage Certificate or Divorce Decree, please include copy of DMV’s Interim Driver’s License/ID Receipt or Social Security Card with new name.
CURRENT NAME (AS LISTED ON ACCOUNT) NEW NAME
CURRENT SIGNATURE ON FILE NEW SIGNATURE
SECTION 5
IDENTIFICATION CHANGE / UPDATE
PREVIOUS IDENTIFICATION # / TYPE / ISSUING AGENCY NEW IDENTIFICATION # / TYPE / ISSUING AGENCY EXP DATE
SECTION 6
MEMBER SIGNATURE (REQUIRED)
My signature authorizes the above change(s) and provides an updated signature to be used for verification purposes. I understand and agree that the changes will be
made to my profile on the listed membership number(s). I further agree and understand that an address change will only affect the Membership if I am the Primary
Member on the listed membership number(s).
By signing this document below, I agree that the Credit Union may from time to time make calls and/or send text messages to me at any telephone number(s) provided
above, including any mobile/cellular telephone numbers and/or numbers that are later converted to mobile/cellular telephone numbers that may or may not result in data
usage and/or charges to me. This is so the Credit Union can service and keep me informed about my account(s), and/or provide fraud, security breach, or identity theft
alerts. I also agree that I may be contacted by the Credit Union service providers and/or any third party making such calls or sending such text messages on its behalf.
The manner in which these calls or text messages may be made to me include, but are not limited to, the use of prerecorded/artificial voice messages and automatic
telephone dialing systems. I understand that I am not required to provide consent as a condition to receiving the Credit Union’s products or services. I may change the
telephone number(s) provided at any time by contacting the Credit Union at 1-800-854-9846.
By also initialing this paragraph below, I further authorize Kinecta to contact me as set forth above, by making calls and/or sending text messages to me at any
telephone number(s) I have provided above, through, but not limited to, the use of prerecorded/artificial voice messages and automatic telephone dialing systems, to
offer products and services that might be of interest to me. I understand that I am not required to provide this additional consent as a condition to receiving the Credit
Union’s products or services.
__________
Initials
MEMBER / JOINT OWNER / AUTHORIZED SIGNER SIGNATURE DATE
MAIL: 1440 Rosecrans Avenue, Manhattan Beach, CA 90266, ATTN : Member Service Support CU/140
or EMAIL: memberservicesupport@kinecta.org or FAX: 310.727.8218
CREDIT UNION USE ONLY
MSC / DEPT# USER ID USER INITIALS DATE MANAGER APPROVAL (ONLY REQUIRED FOR CHANGES TO SECTION 3 & 4)
SECTION 4
TAXPAYER IDENTIFICATION NUMBER (TIN) CORRECTIONS
