Business Account Card

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1 New Update : 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 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/ACCOUNT OWNER INFORMATION Name: Other Trade or D/B/A Names: Type of Entity C Corporation Sole Proprietorship Unincorporated Organization S Corporation Partnership Association/Club Limited Liability Company General Trust/Estate Select Tax Classification: Limited Other: C = C Corporation Limited Liability S = S Corporation P = Partnership ACCOUNT INFORMATION State Organized: EIN/TIN: Business License Number: Issuance : State Issued: Expiration : Mailing Address: City/State/Zip: Physical Address: City/State/Zip: Business Phone: Other Phone: Website: Nature of Business: Membership Eligibility: Business is located in: (choose one) Albemarle County City of Charlottesville Fluvanna County Greene County Louisa County Madison County Nelson County Orange County ACCOUNT TYPE New Membership/Primary Share Savings Account Share Draft/Checking: (choose all that apply) Business Economy Checking Business Plus Checking Business Analysis Checking Money Market Share Certificate/Certificate Additional Services: Order Internet banking/call24 PIN PIN will be mailed within two business days For Checking accounts only: Order VISA CheckMate debit card Add overdraft protection from Savings Initials Page 1 of 4 6/12

2 PRINCIPAL/CONTACT INFORMATION Name: Home Address: Home Phone: Mobile Phone: Driver s Lic. No: State Issued: of Birth: SSN/TIN: City/State/Zip: Business Phone: Issuance : Expiration : Position: PRINCIPAL/CONTACT INFORMATION Name: Home Address: Home Phone: Mobile Phone: Driver s Lic. No: State Issued: of Birth: SSN/TIN: City/State/Zip: Business Phone: Issuance : Expiration : Position: PRINCIPAL/CONTACT INFORMATION Name: Home Address: Home Phone: Mobile Phone: Driver s Lic. No: State Issued: of Birth: SSN/TIN: City/State/Zip: Business Phone: Issuance : Expiration : Position: TIN CERTIFICATION AND BACKUP WITHHOLDING INFORMATION Under penalties of perjury, the undersigned certifies on behalf of the Account Owner that: 1. The number shown on this form is the Account Owner s correct taxpayer identification number,and 2. The Account Owner is not subject to backup withholding because: (a) it is exempt from backup withholding, or (b) it has not been notified by the Internal Revenue Service (IRS) that it is subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified the account Owner that it is no longer subject to backup withholding, and 3. The Account Owner is 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 ). You must 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 the appropriate W-8 BEN form if Account Owner is not a U.S. person. Initials Page 2 of 4 6/12

3 AUTHORIZATION FOR NEW MEMBERSHIP One (1) signature of an authorized person is required to transact business. On behalf of the Account Owner, the undersigned apply(ies) for membership in the Credit Union, and acknowledge(s) receipt of and agree(s) to the terms of this, the Business Membership and Account Agreement, the Funds Availability Policy Disclosure, and additional documents and disclosures the Credit Union has provided, as amended from time to time, and as applicable to the accounts and services requested herein. The undersigned also agree(s) to promptly notify the Credit Union in writing of any changes to the information contained on this document. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. Title: Notary Affidavit Below: Required when submitting application by mail or when a signer is not Notary Public Commission Expires State of _ City/County of Title: Notary Affidavit Below: Required when submitting application by mail or when a signer is not Notary Public Commission Expires State of _ City/County of Title: Notary Affidavit Below: Required when submitting application by mail or when a signer is not Notary Public Commission Expires State of _ City/County of Effective : _ Opened/App d by: Member Verification: Credit Report Check Verify Debit Card IB/C24 PIN OFAC Page 3 of 4 6/12

4 AUTHORIZATION FOR MEMBERSHIP UPDATES On behalf of the Account Owner, the undersigned agree(s) that the changes noted herein amend the previously signed. The undersigned also acknowledge(s) recept of an agreement to the Funds Availability Policy Disclosure and other disclosures, as applicable, for accounts and services requested above. Title: Notary Affidavit Below: Required when submitting application by mail or when a signer is not Notary Public Commission Expires State of _ City/County of Title: Notary Affidavit Below: Required when submitting application by mail or when a signer is not Notary Public Commission Expires State of _ City/County of Title: Notary Affidavit Below: Required when submitting application by mail or when a signer is not Notary Public Commission Expires State of _ City/County of Effective : _ Opened/App d by: Member Verification: Credit Report Check Verify Debit Card IB/C24 PIN OFAC Page 4 of 4 6/12

5 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 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. Complete this form for each Principal/Contact listed on the. PRINCIPAL/CONTACT IDENTITY INFORMATION Business Member Identity Information & Verification Card Principal/Contact Name: Street Address: Residence Business of Birth: City/State/Zip: Nature of business (for business): GOVERNMENT ISSUED IDENTIFICATION NUMBER SSN/EIN: If you do not have a SSN/EIN you must provide AT LEAST ONE of the following: Individual Taxpayer Identification Number: Alien Identification Number: Passport Number: Country: Other Government Issued Document Number: Country: (with photograph or similar safeguard) Describe Document: NOTARY INFORMATION I certify that the information provided above is my true and correct identity information. Principal/Contact Notary Affidavit Below: Required when submitting application by mail or when a signer is not Notary Public Commission Expires State of _ City/County of Effective : _Opened/App d by: Member Number: Government Lists Checked: CIP OFAC Other: Checked by: : UVA UVA Community Credit Credit Union Union Berkmar Drive Drive Charlottesville VA VA uvacreditunion.org Business Account Member Card Identity Information & Verification Card UCU134W Page Page 5 of 1 of 4 1 6/12 6/12

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