Member Services Request
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 when opening a new account.
What this means for you: When you open an account, we will ask for your name, address, date of birth, and other
information that will allow us to identify you. We may also ask to see your driver's license or other identifying
documents.
MEMBER/OWNER INFORMATION
ID Type:
Member/Owner Name:
SSN/TIN:
Mailing Address:
Primary Phone:
City/State/Zip:
ID Number:
ID Issuing State:
City/State/Zip:
ID Exp. Date:
E-Mail:
Security Code:
Employer:
Occupation/Title:
ID Issuing Date:
Date of Birth:
Listed Unlisted
Physical Address:
Primary Phone:
Physical Address:
Primary Phone:
Name #2: SSN/TIN:
Mailing Address: ID Type:
Name #1: SSN/TIN:
Mailing Address: ID Type:
City/State/Zip:
City/State/Zip: ID Number:
ID Number:
ID Issuing State:
ID Exp. Date:
ID Issuing State:
ID Exp. Date:
ID Issuing Date:
Date of Birth:
ID Issuing Date:
Date of Birth:
Listed Unlisted
Listed Unlisted
City/State/Zip:
Joint Owner
Add
CUNA Mutual Group 2008, 10-12, 14 All Rights Reserved
DX1004-e
Other Authorized Signer (Describe): __________________________________Agent
See Account Authorization Card
City/State/Zip:
NEW
UPDATE
IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT
DATE: ________________
ACCOUNT OWNERSHIP
Update
MEMBER NO: ____________________
Physical Address:
The IRS-required certifications set forth in the "TIN CERTIFICATION AND BACKUP WITHHOLDING INFORMATION"
section apply to the member/owner listed above.
Secondary Phone:
Remove
Security Code:
Update
Occupation/Title:
Secondary Phone:
E-Mail:
Employer:
JOINT OWNER/AUTHORIZED SIGNER INFORMATION
Designate the ownership of the accounts and responsibility for the services requested.
Individual Joint Account with Rights of Survivorship Joint Account without Rights of Survivorship
Joint Owner
Other Authorized Signer (Describe): _________________________________
Add
UTMA/UGMA Custodian
Agent
Remove
See Account Authorization Card
Security Code:
Update
Occupation/Title:
Secondary Phone:
E-Mail:
Employer:
Listed Unlisted
Listed Unlisted
Listed Unlisted
Payable on Death (POD)/Trust Account
Beneficiary/POD Payee:
Street:
Beneficiary/POD Payee:
Street:
UTMA/UGMA
Signature:
Date:
TIN CERTIFICATION AND BACKUP WITHHOLDING INFORMATION
City/State/Zip:
Designate Specific Accounts:
Name of Agent: _____________________________________________________________
City/State/Zip:
All Accounts
All Accounts Designate Specific Accounts: ____________________________________________
Physical Address:
Primary Phone:
Name #3: SSN/TIN:
Mailing Address: ID Type:
City/State/Zip: ID Number:
ID Issuing State:
ID Exp. Date:
ID Issuing Date:
Date of Birth:
Listed Unlisted
City/State/Zip:
Joint Owner
Other Authorized Signer (Describe): __________________________________
Add
Add
Agent
Remove
See Account Authorization Card
Security Code:
Update
Occupation/Title:
Secondary Phone:
E-Mail:
Employer:
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
SSN/TIN:
Date of Birth:
Add Remove
Update
SSN/TIN:
Date of Birth:
___________________________________________ (as custodian for _______________________________________________________ (minor)
under the Uniform Transfers/Gifts to Minors Act.) Minor's SSN/TIN: __________________________________________________________
Agency
Remove
Update
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.
JOINT OWNER/AUTHORIZED SIGNER INFORMATION (continued)
DX1004-e
Listed Unlisted
Other:
Other:
Add Remove
Update
Add Remove
Exempt payee code (if any) Exemption from FATCA reporting code (if any)
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signature
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FOR CREDIT UNION USE ONLY
Date of Membership: ___________
List Verification Completion Date: _______________
By: _________________________________________________________________________
Opened/Approved By: ____________________ Membership Eligibility: _____________________________
Verification List(s) Checked:
Overdraft Protection Opt-in Completion Date: _________________________
AUTHORIZATION
X
Member/Owner
Date
By signing or otherwise authenticating, I/we agree to the terms and conditions of the Membership and Account Agreement,
Truth-in-Savings Disclosure, Privacy 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 the agreements and disclosures applicable
to the accounts and services requested herein. 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 Transfers Agreement and Disclosure. All of the terms, conditions, form of account
ownership, account selection and other information indicated on this document applies to all of the accounts listed unless the credit
union is notified in writing of a change. I/We agree that any updates identified herein amend the previously signed Member Services
Request(s), and are subject to the terms and conditions of the applicable disclosures noted above.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to
avoid backup withholding.
X
Joint Owner/Authorized Signer
Date
X
Joint Owner/Authorized Signer
Date
X
Joint Owner/Authorized Signer
Date
Other: _________________________________________________
OFAC
DX1004-e
Member Verification: _______________________________
Reports Checked: Other: ________________________________________________Credit Report Check Verification Report
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signature
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signature
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signature
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signature
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