Personal Membership Application

Transcription

1 Personal Membership Application Ownership: Member # Self-Help Credit Union, including its divisions may be referred to as "Credit Union." (To be provided by the Credit Union) Member Name Important Information About Procedures for Opening a New Account 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 to you: When you open an account, we will ask for your name, address, date of birth or other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents. Social Security Number Second Name Line ID Type Number/Value Issued By Mother's Maiden Name Expiration of Birth Gender Physical Address Mailing Address Other Home Phone Cell Phone Work Phone Address Employer Occupation Membership Eligibility Requirements - Primary Member Only: Eligibility Type: Group: * If eligible through The Center for Community Self-Help: The Center for Community Self-Help is a 501(c)(3) nonprofit corporation dedicated to creating and protecting ownership and economic opportunity for people of color, women, rural residents, and low-wealth families and communities. Membership in the Center for Community Self-Help requires a $5 fee, which is a tax-deductible contribution. Additional Information - Primary Member Only: Providing this additional information is optional. We ask for it because it helps us better understand who our Members are and how we can better serve them. It also helps us when writing proposals to try and raise money for the Credit Union and when reporting on the same. The Credit Union does not discriminate on the basis of race, religion, national heritage ethnic background, gender or sexual preference. I prefer not to answer this information with the Credit Union. What is your primary racial background? American Indian/Alaska Native Asian Black/African American Native Hawaiian/Other Pacific Islander White Other (Please Indicate) Are you Hispanic/Latino? Yes No How many family members are in your household? What is your approximate household income? Referral Information - How did you hear about the Credit Union? Friend, Family or Co-Worker Dissatisfaction SRI Search SH Borrower SH Loan Borrower Ad/Mailer Article/Publication (Please list) (Please list) Business or Professional Referral Event/Conference Internet Rate Search (Please list) (Please list) (Please list) Other: (Please list) Member Signature FOR OFFICE USE ONLY Branch: Name of MSR: Member deposits are insured up to $250,000 by the National Credit Union Administration (NCUA).

2 New Account Selection Primary Member Name: Member #: SSN #: Account Type: Suffix #: Ownership Type: Individual Joint with Right of Survivorship* Joint Owner Information First Name Middle Initial Last Name Suffix Social Security Number ID Type Number/Value Issued By Expiration of Birth Gender Physical Address Mailing Address Mother's Maiden Name Home Phone Cell Phone Address Employer Work Phone Occupation Joint Owner Information First Name Middle Initial Last Name Suffix Social Security Number ID Type Number/Value Issued By Expiration of Birth Gender Physical Address Mailing Address Mother's Maiden Name Home Phone Cell Phone Address Employer Work Phone Occupation *Joint account with Right of Survivorship - Definition Right of Survivorship: We understand that by establishing a joint account with right of survivorship under the provisions of N.C. Gen. Statute that: (1) The Credit Union may pay the money in the account to, or on the order of, any person named in the account unless we have agreed with the Credit Union that withdrawals require more than one signature; and (2) Upon the death of one joint owner the money remaining in the account will belong to the surviving joint owners and will not pass to the heirs of the deceased joint owner or be controlled by the deceased joint owner's will. We DO elect to create the right of survivorship in this account Substitute W-9 - TIN Certification I certify in accordance with IRS W-9 instructions and under penalties of perjury, that: 1. The number shown on this form is my correct taxpayer identification number, 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. 3. I am a U.S. person (including a US resident alien). [Cross out item 3 if you are not a U.S. person, and initial here: ] are incorporated therein. I/we acknowledge receipt of the abovementioned disclosures, and any agreements and disclosures applicable to the accounts and services requested herein. Additionally, I/we specifically consent and agree that the Credit Union may provide the abovementioned legally required disclosures electronically on the Credit Union website, or in writing, or both. Agreement and Authorization Signatures By signing below, I/we agree to the terms and conditions of the Membership and Account Agreement, Truth-in-Savings Disclosures, Funds Availability Policy, Electronic Fund Transfers Agreement and Disclosure, Privacy Notice Disclosure and Rate and Fee Schedules; and to any amendment the Credit Union makes from time to time which I/we understand that in order to become, and remain, an active member of the Credit Union, a minimum of $5 must be maintained on account with the Credit Union. Yes, I/we want to open my/our Credit Union account(s) and join the Credit Union if my/our membership has not already been established. I/we hereby authorize the Credit Union to open the account(s). Furthermore, I/we affirm our commitment to the mission of the Center for Community Self-Help and acknowledge that I/we are making a $5 membership contribution to CCSH (if applicable). Primary Member Signature Joint Owner Signature Joint Owner Signature

3 Personal Membership Application Help Sheet Thank you for your interest in membership with Self Help Credit Union. Please read the following information to assist you in completing the necessary information for membership. If any part of the required information is not received, your membership will be delayed until such time as all necessary items are received. If you have any questions as you complete this form, please contact your local branch for assistance. Ownership Indicate the type of account to establish: Personal, Custodial, Estate, Minor, Minor UTMA. All accounts established require additional forms based on the type of account opened. Member Number This will be assigned by the Credit Union. Primary Member Information Complete the Primary Member information section completing all information. If a section does not apply to you, please indicate by N/A. Member Name Enter your name as the account should be titled Social Security Number Enter your full social security number or ITIN Second Name Line - Leave Blank Mother s Maiden Name Enter your Mother s Maiden Name ID Type Enter ID type for verification. Acceptable types include: Driver s License, Passport, Issued ID or Military ID Number/Value Enter ID number for ID type Issued By Enter Issuing or Agency Expiration Enter expiration date of ID Type of Birth Enter of Birth date will format to mm/dd/yyyy Gender Enter Gender Physical Address Enter you full physical address including city, state and zip Mailing Address Enter a mailing address if different from physical address Other Address Leave Blank Home Phone Enter Home phone number (Note: If you have a cell phone as your home phone list here also) Cell Phone Enter your Cell phone number Work Phone Enter your Work phone number Address Enter your primary address Employer Enter your current Employer (Note: If Retired please list last Employer) Occupation Enter your current Occupation (Note: If Retired please list last Occupation) Member Eligibility Requirements Designation Follow the guidelines below to determine the appropriate membership eligibility designation for you. Eligibility Type Choose Eligibility Type from list as: Geographic, Employer/Association or Family. See below for definition of each. Geographic The Durham office does not fall into this category. Self Help offices are located in the following counties: Brunswick, Buncombe, Forsyth, Greene, Guilford, Haywood, Henderson, Jackson, Lenoir, New Hanover, Polk, Scotland, Transylvania, and Wilson.

4 Group Choose Group from list as: Live, Work, Worship or Attend School in any of the counties listed above. Select Employee Group/Association If you reside in a state other than North Carolina, or if you plan to submit your application to our Durham office, please choose Select Employee Group/Association, and follow the instructions for joining through the Center for Community Self-Help. Family Member An immediate family member is defined as a spouse, parent, sibling, or child. Additional Information This demographic data is used to assess our effectiveness as a nonprofit organization in serving our communities, so while this section is optional, we strongly encourage your participation. All information provided by the applicant is handled in strict accordance with our privacy policy.

5 New Account Selection Help Sheet Thank you for your interest in membership with Self Help Credit Union. Please read the following information to assist you in completing the necessary information for membership. If any part of the required information is not received, your membership will be delayed until such time as all necessary items are received. If you have any questions as you complete this form, please contact your local branch for assistance. Member Number This will be assigned by the Credit Union. Account Type Full account descriptions are available on our Website any Credit Union branch or the Durham office. Indicate the type of account being opened. Please note that a form needs to be completed for each type of account (i.e. Savings, Checking, Money Market, etc.) The suffix will be system assigned and will be entered by a Credit Union employee. Ownership Indicate the ownership for the account. The following describes the types of ownership: Individual Account (without a named Payable on Death Beneficiary) is an Account which is owned by one individual. The owner of the account has full transaction authority. Upon the death of such individual, the remaining funds belong to the individual s estate. Joint Account with Right of Survivorship is an Account which is owned by two or more individuals. Each joint owner has full transaction authority and ownership of account funds. Upon the death of one of the joint owners, the remaining funds belong equally to all surviving joint owner(s). Joint Owner Information Complete the Joint Owner information for all joint owners on the account, making sure to complete all information. If a section does not apply, please indicate by N/A. First Name, Middle Initial, Last Name & Suffix Enter your name as the joint owner Social Security Number Enter your full social security number or ITIN ID Type Enter ID type for verification. Acceptable types include: Driver s License, Passport, Issued ID or Military ID Number/Value Enter ID number for ID type Issued By Enter Issuing or Agency Expiration Enter expiration date of ID Type of Birth Enter of Birth date will format to mm/dd/yyyy Gender Enter Gender Physical Address Enter you full physical address including city, state and zip Mailing Address Enter a mailing address if different from physical address Mother s Maiden Name Enter your Mother s Maiden Name Home Phone Enter Home phone number (Note: If you have a cell phone as your home phone list here also) Cell Phone Enter your Cell phone number Address Enter your primary address Employer Enter your current Employer (Note: If Retired please list last Employer) Work Phone Enter your Work phone number Occupation Enter your current Occupation (Note: If Retired please list last Occupation)

6 Additional Credit Union Products & Services Health Savings Account (HSA) The Credit Union offers HSA checking accounts. An HSA is an account designed for use with a High-Deductible Health Plan. If eligible, additional paperwork is required to open this account. The Credit Union also offers a debit card for these accounts. Online Banking Get access to your Credit Union account information, as well as e-statements (free) and Bill Pay (read the Bill Pay description for information on how to avoid the monthly fee for this service). Access this service via our website The Credit Union will provide you with your online banking username and temporary password. Bill Pay Access this service at no charge when you have any two of the following three Credit Union services: direct deposit, e-statements, and the Self-Help Credit Union debit card. Otherwise, a monthly service fee is charged (see the Credit Union fee schedule for details). E-ments Replace paper statements with statements that you view online. Connect to E-statements free of charge using our online banking service. Debit and ATM Cards Self-Help Credit Union offers free Debit and ATM cards. The cards can be used nationwide with surcharge-free access to your Credit Union funds at ATM terminals that display the CO-OP network logo. A Credit Union checking account is required with the debit card. Audio Banking Request your individualized username and password from the Credit Union after establishing membership, and access your Credit Union account information by calling toll-free. Overdraft Coverage Overdraft Transfer: The source account for overdraft transfer must be a Credit Union savings or checking account (term certificates not included). A fee is charged for each transfer (see the Credit Union fee schedule for fee details). Overdraft Line of Credit: Use this loan product to cover shortages in your Credit Union checking account and to avoid NSF fees. Applicants for an overdraft line of credit must meet the loan approval guidelines of the Credit Union. The overdraft line of credit carries an interest rate (see the Credit Union fee schedule for details). Direct Deposit Contact your employer about depositing your paychecks into your Credit Union savings or checking accounts. Also, if you receive payments from the federal government, then look into the U.S. Treasury Department s Go Direct program for direct deposit of those funds into your Credit Union deposit accounts. Personalized Printed Checks Checks can be ordered at the time you open your checking account or money market account, or you can order checks on your own at any time after opening the account. To order checks you will need our routing number and your Credit Union checking account number. The check ordering fee will be taken out of your checking account. Credit Cards Any credit card applicant must meet the loan approval guidelines of the Credit Union. A separate credit card application should be completed.

7 Substitute W-9 - TIN Certification Read this section thoroughly. Sign and date as required. Account disclosures are available on our website and at the Credit Union. Signatures The New Account Selection Form must be signed by the Primary Member and all joint owners.