Austin City Employees Credit Union

711 4th Ave NE, Austin, MN 55912

(507) 433-6580 or (877) 918-1178 Toll Free                  

PRINT THIS APPLICTION, COMPLETE AND MAIL TO THE CREDIT UNION WITH MINIMUM DEPOSIT OF $5.50

 Under penalties of perjury, I certify that:

The number shown on this form is my correct taxpayer identification number,

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 I am a U.S. person (including a U.S. resident alien).

 

 

Member/Owner _________________________________________

Street_____________________________________________

City/State/Zip ___________________________________         SSN/TIN ____________________

Home Phone (       ) ___________________________Driver’s Lic. ________________________

Work Phone (       ) ___________________________ Date of Birth ________________________

E-mail (optional) _____________________________Employment _________________________

 Eligibility for Membership: _______________________________________________________________________________

 

                 Designate the ownership of the share account.

 

                 _____ Individual                  ______ Joint with Survivorship

 

 Joint Owner __________________________________SSN/TIN__________________________

  Street _______________________________________ Driver’s Lic. No. ___________________

  City/State/Zip _________________________________ Date of Birth ______________________

Home Phone (    ) ____________________    Employment ________________________________

Work Phone (    ) ____________________     E-mail (optional) ______________________________

 

 2^nd Joint Owner ___________________________ SSN/TIN ____________________________

 

Street ___________________________________ Driver’s Lic. No. _______________________

City/State/Zip ______________________________  Date of Birth  ________________________

Home Phone (    ) ___________________       Employment_______________________________

Work Phone (    ) _____________________   E-mail (optional_____________________________

 

Payable on Death (POD) Account:

Beneficiary/Payee ____________________   Beneficiary/Payee_____________________________

Street ______________________________   Street ____________________________________

City/State/Zip ________________________  City/State/Zip _______________________________

 

By signing below, I/we certify that the information on the Account Card is complete, and I/we agree to the terms and conditions of the Share Account Agreement and the Truth-in-Savings Disclosures (Rate and Fee Schedule) and to any amendment the Credit Union makes from time to time which are incorporated herein.  I/we acknowledge receipt of a copy of the Agreement and Disclosures.  The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

 

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 who opens an 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 objects.

 

 

 

X ___________________________________                 X ____________________________________

                 Signature                                      Date                                             Signature                                      Date

X _________________________________    X ___________________________________

                 Signature                                      Date                                             Signature                                      Date

Member Number (Office use only)