MEMBERSHIP APPLICATION


ACCOUNT TYPE: All of the terms, conditions, form of account ownership, account selection and other information indicated on this application apply to all of the accounts listed unless the Credit
Union is notified in writing of a change:
                     ______ Share/Savings                           ______ Money Market
                     ______ Share Draft/Checking                              ______ HSA
                     ______ Share Certificate/Certificate                    ______ Other

ACCOUNT #:____________________________________________
 

ACCOUNT INFORMATION:
______Individual      ______Joint w/Rights of Survivorship      ______Joint w/o Rights of Survivorship

Primary Owner Name:____________________________________________________________________ Social Security # (tax id #): _________________________________________________

Home Address: _________________________________________________________________________________________________________________________________________________

City: ______________________________________________________ State: __________________________ Zip: ____________________________________

Date of Birth:____________________________Home Phone Number:__________________________________________ Cell Phone Number:__________________________________________

E-Mail Address: ________________________________________________________ Driver's License Number:___________________________________________________________________

Employed By (include location): ___________________________________________________________ Work Phone Number:______________________________________________________

Membership Eligibility:_________________________________________________________________________________________________________________________________________

Joint Owner Name:___________________________________________________________________ Social Security # (tax id #): _____________________________________________________

Home Address: _______________________________________________________________________________________________________________________________________________

City: _____________________________________________________ State: __________________________ Zip:____________________________________

Date of Birth:_____________________________ Home Phone Number: ________________________________________ Cell Phone Number:__________________________________________

E-Mail Address: _______________________________________________________ Driver�s License Number:___________________________________________________________________


TIN CERTIFICATION AND BACKUP WITHHOLDING INFORMATION

Under penalties of perjury, I certify that:
(1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), AND
(2) I am not subject to backup withholding either because 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 the IRS has notified me that I am no longer subject to backup withholding (does not apply to real estate transactions, mortgage interest paid, the acquisition or abandonment of secured property, contributions to an individual retirement account (IRA), and payments other than interest and dividends), or I am exempt from backup withholding, AND
(3) I am a U.S. person (including a U.S. resident alien)

CERTIFICATION INSTRUCTIONS.
You must cross out item (2) above if you have been notified by the IRS that you are currently subject to backup withholding because of underreporting interest or dividend on your tax return. I have read and understand all disclosures .

INCLUDE INITIAL $5.00 DEPOSIT AND $1.00 MEMBERSHIP FEE

I/we hereby make application for membership in the credit union named below, and agree to conform to its bylaws and amendments thereof, copies of which have been made available to me, and to subscribe for at least one (1) share.

By signing below, I/we agree to the terms and conditions of the Membership and Account Agreement, Truth-in-Savings Disclosure, Funds Availability Policy Disclosure, if applicable, 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 agreements and disclosures applicable to the accounts and services requested herein. If an access card or EFT service is requested and provided, I/we agree to the terms of and acknowledge receipt of the Electronic Fund Transfers Agreement and Disclosure.
 
By signing this card, I/we authorize the credit union to obtain credit reports in connection with this application for membership, services and/or credit, and for update, renewal or extension of the credit received, if applicable. If you request, the credit union will tell you the name and address of any bureau from which it received a credit report on you.

The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.


Primary Owner (Signature): ____________________________________________________________________________Date:_________________________________


Joint Owner (Signature): ______________________________________________________________________________Date:_________________________________


JOINT SHARE ACCOUNT AGREEMENT (*NOT TRANSFERABLE)

INDIANA LAKES FEDERAL CREDIT UNION is hereby authorized to recognize any of the signatures subscribed in the payment of funds or the transaction of any business for this account. The joint owners of this account hereby agree with each other and with said credit union that all sums now paid in on s hares, or heretofore or hereafter paid in on shares by any or all of said joint owners to their credit as such joint owners with all accumulations thereon, are and shall be owned by them jointly, with right of survivorship and be subject to the withdrawal or receipt of any of them, and payment to any of them or the survivor or survivors shall be valid and discharge said credit union from any liability for such payment. The joint owners also agree to the terms and conditions of the account as established by the credit union from time to time.
Any or all of said joint owners may pledge all or any part of the shares in this account as collateral security to a loan or loans from the credit union.
The right or authority of the credit union under this agreement shall not be changed or terminated by said owners, or any of them except by written notice to said credit union which shall not affect transactions theretofore made.

ACCOUNT SERVICES
______ Payroll Deduction/Direct Deposit                                         ______ ATM Card
______Overdraft Protection (indicate transfer priority):                 ______  Debit Card
               ____________________________________                  ______   Audio Response
______PC Access/Internet Banking Other:  



ACCOUNT DESIGNATIONS
______ Payable on Death (POD)/Trust Account
Beneficiary/POD Payee:_____________________________________________________ Beneficiary/POD Payee: _____________________________________________________
Street:___________________________________________________________________ Street:___________________________________________________________________
City/State/Zip:____________________________________________________________ City/State/Zip:_____________________________________________________________
______UTMA/UGMA (as custodian for ______________________________________________________________________ (minor) under the Uniform Transfers/Gifts to Minors Act)
Minor�s SSN/TIN:__________________________________________________
______Agency                      ______ Agent only for HSA
                         Print Name of Agent:________________________________________________________________
                        Signature: _________________________________________________________Date:_________________________________
Other:_________________________________________________          ______ See Account Authorization Card



FOR CREDIT UNION USE ONLY:            _____ See Account Change Card           _____ See Insurance Beneficiary Card
Date of Membership: _________________________ Opened/App�d by: ______________ Member Verification: ________________
_____ Credit Report                 _____ Check Verify                _____ PIN Request
_____ Access Card                  _____ Audio Response            _____ PC Access/Internet Banking



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