Membership Application - Lge Community Credit Union

Membership Application.

OFFICE USE ONLY

Acct. Number ___________________Teller Number __________________

Date _______________ Approved By ______________________________

IMPORTANT INFORMATION ABOUT PROCEDURE(S) 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 for you: When you open an account, we will ask you 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.

A copy of current government issued I.D. is required of all members.

(1) JOINT INFORMATION

PRIMARY MEMBER INFORMATION

Per the Patriot Act, a residential address is required for all Joint Members.

Name _____________________________________________________________

Name ____________________________________________________________

Address ___________________________________________________________

Address ____________________________________________________________

City, State, Zip ______________________________ County _________________

City, State, Zip ______________________________ County _________________

SS#_____________________________Date of Birth _______________________

Per the Patriot Act, if you list a P .O. Box for your mailing address, you must

Home#__________________________Cell# _____________________________

also provide a residential address:

Email Address ______________________________________________________

Address ___________________________________________________________

Employer__________________________Work# __________________________

Occupation _________________________ Monthly Gross Income__ ___________

City, State, Zip ______________________________________________________

ID Type/State_________________________________ID#___________________

ID Expiration Date_________________US Citizenship (Yes / No)_____________

If you have lived at this address less than 2 years, please provide prior

address: ____________________________________________________

(2) JOINT INFORMATION

City, State, Zip ______________________________________________________

Per the Patriot Act, a residential address is required for all Joint Members.

Name ____________________________________________________________

SS#_____________________________Date of Birth _______________________

Address ___________________________________________________________

Home#__________________________Cell# _____________________________

City, State, Zip ______________________________ County _________________

SS#_____________________________Date of Birth _______________________

Email Address ______________________________________________________

Home#__________________________Cell# _____________________________

Employer__________________________Work# __________________________

Email Address ______________________________________________________

Occupation _________________________ Monthly Gross Income___ __________

Employer__________________________Work# __________________________

Occupation _________________________ Monthly Gross Income__ ___________

ID Type/State_________________________________ID#___________________

ID Type/State_________________________________ID#___________________

ID Expiration Date_________________US Citizenship (Yes / No)_____________

ID Expiration Date_________________US Citizenship (Yes / No)_____________

I certify that I am eligible for membership through:

___________________________________________________________________

(County OR Partner Group OR Name and Relationship of Eligible Party)

REQUESTED PRODUCTS AND SERVICES (MARK ALL THAT APPLY):

p Savings *

p Checking Account (Select One):

p VISA

®

Debit Card (Select Card Recipients):

p Additional Savings 1

p High Rate

p Primary

p Additional Savings 2

p Simply Free

p 1) Joint

p Money Market Account

p Order New Checks (Standard Checks Will Be Ordered)

p 2) Joint

(Minimum $2,500 Balance)

p Online Banking / eStatements / Memberline phone banking

p Checking Overdraft Protection (From Savings)

•

p Order New Money Market Checks

Bill Pay (Free With Any Checking Account)

INDIVIDUAL / JOINT ACCOUNT HOLDER INFORMATION - PLEASE READ: I hereby make application for membership in and agree to conform to the Bylaws, as amended, of LGE Community Credit Union

(the “credit union”). By signing below I further certify that: I am within the field of membership of this Credit Union; the information provided on this application is true and correct; and my written signature on this application applies to all accounts under my

name at the Credit Union. I also agree to be bound to the terms and conditions of any account that I have in the Credit Union now or in the future. These include, but are not limited to, the Membership and Account Agreement, Truth in Savings Act, Funds

Availability Policy, Electronic Funds Transfer Agreement, Privacy Notice, etc.

INTERNAL REVENUE CODE AND BANK SECRECY ACT DISCLOSURES: The Internal Revenue Service (IRS) does not require the applicant’s consent to any provision of this document other than the certification

required to avoid backup withholding. I understand and agree that the Patriot’s Act of 2001 obligates all persons seeking to open an account to fully comply with the identity verification requirements of the Bank Secrecy Act, as amended from time to time.

TRANSACTIONS TO/FROM ANY ACCOUNTS MAY BE LIMITED UNTIL ID VERIFICATION OF ALL APPLICABLE PERSONS IS COMPLETED.

FEDERAL TAXPAYER IDENTIFICATION AND BACKUP WITHHOLDING CERTIFICATION: Under penalties of perjury, each signing party certifies that: (1) The number shown on this form is my correct

taxpayer identification number, (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. person (including a U.S. resident alien). Complete a W-8 BEN if you are not a U.S. person.

*Membership with LGE Community Credit Union requires that all members have a savings account and maintain a minimum balance of $5.

By my signature, I/we authorize LGE Community Credit Union to verify the information submitted and to obtain credit reports and any other information as may be required concerning the statements made above.

Primary Signature _______________________________________________________________________ Date ______________________________

(1)Joint Signature _______________________________________________________________________ Date ______________________________

(2)Joint Signature _______________________________________________________________________ Date ______________________________

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This credit union is federally insured by the National Credit Union Administration.