Membership Application Primary Member/ Signer Home Address (No PO Box) — Required ANWDD! Zip Code Iprence NSC. Cit State ailing Address (Itdifferent from abo Aos . NYS _ 94 de State de Zip C pe. vt Gp» ent Employer Email Address Joint Account Holder Last Name First Name \ ) Current Employer Work Phone / Social Security # Date ¢ Birth First ID Type ~ Second ID Type Designation of Beneficiary (Does Not Preclude The Joint Account Holder's Right of Survivorship) nthe event of my death, or the mutual death of the joint aecount heldu , Wwe authorize USA Federal Credit Union to pay the b these accounts to Name 0! Nneficiary- First Mi jocsal Security & Date of Birth Adan Navy Federd?'@¥adit Union Checking - Clioose One Certification of Taxpayer Identification Number (W-9) Under penalties of perjury, | certify that: Bronze | (1) The number shown on this form is my correct taxpayer Silver } identification number (or | am waiting for a number to } be issued to me) and Gold (2) | am not subject to backup withholding because (a) | am FEZ Access H exempt from backup withholding, or (b) | have not been | notified by the Internal Revenue Service (IRS) that | am ” Five-Star | subject to backup withholding as a result of a failure i report all interest or dividends, or (c} the IRS has notified me that | am no longer subject to backup withholcing, and ) jlamé . arson Money Market } 3) 1am a U.S. perso s Perntic | Certification instructions Share Certificate - Term ee You must cross out Item 2 (above) if you have been notified by the IRS you are ently subject to backup withholding Investment Products ncluding U.S. resident alien} IRA Share Certificate - Term | Account Agreement Other Services |/We have received a copy of the All About Your Credit Union } Accounts and Schedule of Fees and agree with the terms Debit Card and conditions for the use of these services, All membership Receive eStatements* and avoid fees \ applications are subject to verification of information provided and eligibility prior to granting membership. We may verify your application for an account through an acco 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. Loans Please contact me regarding a USA Federal: Home Loan Auto Loan ' Signature Loan The Internal Revenue Service coes not require your consent.to any provision of this document other than the certificgy 6 red ty = it a Personal Line of Credit "Credit Card | Other —— | Signature of Joint Account Holder Date Member Identification Requirements lc government fight the funding of terrorism and money wundering a law req) financial insttutions to obt. fity and ree ation that identifies #ach persion who opens an mecourt ¢ | or @ new mmerriber reletionship with our un | For Credit Union Use Only | What th: ns for you: When you open an account, we wil! ask tor your nn o— nane date of birth, and other informat will allow us t | ChexSystems Verification # entity yc May BSO & anse of other identifying | cument Lit 5 C. | Opened 4 Braach We ye, 2 | ——— } | Membership Office SEG IDF I Wiixs EFTA00124782