Membership Application

Membership Application Account Number: H ome Address (No PO Box) -*squired 4 ibfre.-.e... r))r. Oct3 CI c State Zi Code ailing Address ( f-different from above) rArnin . Yr". pity State Zip Code kepi> Cot Ornri-- Current Employer Email Address Joint Account Holder Last Name First Name MI Current Employer Work Phone / / Social Security # Date of Birth First ID Type Second II) Type Designation of Beneficiary (Does Not Preclude The Joint Account Hordes Ret of Surthorship) in the event of my dibMit, of the mutual death of tke pint Aucksk hukfunsi of this account, I/we authorize USA Federal Credit Union to pay the balance of thls/these accounts to: Name of Beneficiary-Lev First MI / / Social Security a Date eh 01 nit Addle** City Navy Federdineadit Union Zea Code 1 Checking - Choose One u Bronze O Silver Gold EZAccess E FiveStar Investment Products 1 Money Market • Share Certificate - Term IRA Share Certificate - Term Other Services Debit Card .! Receive eStatements* and avoid fees saarst race hitrenet access Loans Please contact me regarding a USA Federal: Auto Loan Home Loan Personal Line of Credit Other —I Signature Loan 'Credit Card Member identification Requirements To help the ipernment fel the fUrxliflp. Of terOriSM ard money burxtertne activities. Fedora: low requires all franca/ inshmtions to obtain, verify and retold information that identities, oath person who opens an account ce creates a new molter metionstiip wtth cur credit union. what this means for wu: When you open an scowl. we will ask for your nine. esti. date of birth, and other Information dun will aloes us to irlentity may *so ask to see tffr r rivers license or other identshzing 4.0eurnen Certification of Taxpayer identification Number (W-9) 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 to me) and (2) I am not subject to backup withholding because (a) t am exempt from backup withholding, or (b) I have not been noutied by the Internal Revenue Service (IRS) That I em 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. person (including U.S. resident alien). Certification instructions You must cross out Item 2 (above) If you have been notified by the IRS you are currently subject to backup withholding. Account Agreement I/We have received a copy of the All About Your Credit Union Accounts and Schedule of Fees and agree with the terms and conditions for the use of these services. All membership applications are subject to verification of information provided and eligibility prior to granting membership. We may verify your application for an account through an account verification service and reserve the right to deny any application based on the results of negative information received through that service. If we deny your application we will provide you with the name, address and telephone number of the account verification service which provided us with this information. The Internal Revenue Service does not require your centerline any provision of this document other than the Signature of Joint Account Holder Date For Credit Union Use Only ChaxSystems Verification Opened by klernbersboOrtIcer SEG WV I. EFTA00124782