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Joint Owner
Other Authorized Signer (Describe): __________________________________Agent
JOINT OWNER/AUTHORIZED SIGNER INFORMATION (continued)
Add
Update
Remove
See Account Authorization Card
Name #3: SSN/TIN:
Mailing Address: ID Type:
City/State/Zip:
Physical Address:
City/State/Zip:
Primary Phone:
Listed Unlisted
ID Number:
ID Issuing State:
ID Exp. Date:
E-Mail:
ID Issuing Date:
Date of Birth:
Security Code:
Secondary Phone:
Listed Unlisted
Employer:
Occupation/Title:
ACCOUNT TYPES
Share/Savings:
Mobile Banking:
Overdraft Protection
Indicate transfer priority:
Add
Share Draft/Checking:
Add
Share Certificate/Certificate:
Money Market:
Remove
Audio Response:
ATM Card:
1. ___________________________________________________
ACCOUNT DESIGNATIONS
Debit Card:
Other:
Remove
Add
2. ___________________________________________________
4. ___________________________________________________
Add Remove
Add Remove
Add Remove
ACCOUNT SERVICES
Add Remove
Remove
Add Remove
Add
Bill Payment:
Remove
3. ___________________________________________________
Add Remove
Internet Banking:
Add Remove
Other:
Other:
Add Remove
Update
Add Remove
Payable on Death (POD)/Trust Account
All Accounts Designate Specific Accounts:
Add
Update
Remove Add
Update
Remove
Beneficiary/POD Payee: Beneficiary/POD Payee:
SSN/TIN:
Date of Birth:
SSN/TIN:
Date of Birth:
Street: Street:
City/State/Zip: City/State/Zip:
UTMA
___________________________________________ (as custodian for _______________________________________________________ (minor)
under the Washington Uniform Transfers to Minors Act.) Minor's SSN/TIN: __________________________________________________
Agency
Name of Agent: _____________________________________________________________
Signature:
Date:
All Accounts Designate Specific Accounts: ____________________________________________
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. Check the box for 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. By checking this box, this serves to strike
out the language related to underreporting. 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)
DXWA13-e
