Account Type

All of the terms, conditions, for of account ownership, account selection and other information indicated on this card apply to all the accounts listed unless the Credit Union is notified in writing of this change.
Please select an option below:
The account number for each of the accounts listed consists of the suffix added to the end of the Member Number listed in the *MEMBER APPLCATION AND OWNERSHIP INFORMATION* section. If this Card applies to more than one account of the same type, more than one suffix will be listed for this account type.

Member Application and Ownership Information

Tin Certification and Backup Withholding Information

Under penalties of perjury, I certify that:

  1. The number shown on the 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, (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 secition 301.7701.7).

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. Cross out item 3 and complete a W-8 BEN if you are not a U.S. person.

Authorization

By signing below, I/we agree to the terms and conditions of the Membership and Account Agreement, Truth in Savings 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 have received and read 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 an acknowledge receipt of the Electronic Fund Transfers Agreement and Disclosure. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

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