Fields marked with * are compulsory 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/OWNERSHIP INFORMATION First Name * Last Name * Mailing Address City State SelectALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Physical Address City State SelectALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Primary Phone Primary Phone TypePrimary Phone TypeListedUnlisted Secondary Phone Secondary Phone TypeListedUnlisted Employer SSN/TIN Driver's Lic Number ID Issuing State SelectALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY ID Issuing Date ID Exp. Date Date of Birth E-mail * Security Code The IRS-required certifications set forth in the "TIN CERTIFICATION AND BACKUP WITHHOLDING INFORMATION" section apply to the member/owner listed above. Account Ownership Select OwnershipIndividualJoint Account with Right of SurvivorshipJoint Account without Right of Survivorship Number of Joint Owner(s) Select Number of Joint Owner(s)123 JOINT OWNER 1 Joint Owner Name Street Address City State ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Primary Phone Primary Phone TypeListedUnlisted Work Phone E-mail SSN/TIN Driver's Lic. Number Date of Birth Password JOINT OWNER 2 Joint Owner Name Street Address City State ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Primary Phone Primary Phone TypeListedUnlisted Work Phone E-mail SSN/TIN Driver's Lic. Number Date of Birth Password JOINT OWNER 3 Joint Owner Name Street Address City State ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Primary Phone Primary Phone TypeListedUnlisted Work Phone E-mail SSN/TIN Driver's Lic. Number Date of Birth Password Joint Owner/Authorized Signer Information Select Joint Owner/Authorized Signer Info.Joint OwnerUTMA/UGMA CustodianAgentOther Authorized Signer Joint Owner Change Select Joint Owner ChangeAddUpdateRemove Describe Other Authorized Signer Account Types Account Number AddShare Draft/CheckingShare Certificate/CertificateMoney MarketIRA SharesIRA CertificateChristmas ClubSpecial ClubKasasa Cash CheckingKasasa Cash Back CheckingKasasa Saver RemoveShare Draft/CheckingShare Certificate/CertificateMoney MarketIRA SharesIRA CertificateChristmas ClubSpecial ClubKasasa Cash CheckingKasasa Cash Back CheckingKasasa Saver ACCOUNT SERVICES Account Number AddDebit CardAudio ResponseInternet BankingMobile BankingBill Payment RemoveDebit CardAudio ResponseInternet BankingMobile BankingBill Payment Overdraft ProtectionSelectUpdate Indicate Transfer Priority Indicate Transfer Priority 2 Indicate Transfer Priority 3 Indicate Transfer Priority 4 I accept Terms & Conditions 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. AUTHORIZATION 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. Signature of Individual * Date
