Fields marked with * are compulsory First Name * Last Name * Street Address * City StateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Primary Phone * Primary Phone Type *ListedUnlisted Work Phone E-mail * SSN/TIN * Driver's Lic. Number Date of Birth * Membership Eligibility Type *---EmployerImmediate Family Member Membership Eligibility (Name of Employer or Family Member) * Name of Employer or Family Member * Account Ownership IndividualJoint Account with Right of SurvivorshipJoint Account without Right of Survivorship ACCOUNT DESIGNATION - Payable on Death(POD)/ Trust Account Beneficiary/POD Payee Street Address City StateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip SSN Date of Birth ACCOUNT DESIGNATION - UTMA/UGMA Name of Minor Minor SSN/TIN Account TypeCheckingSavings
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), 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, and
(3) I am 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 301.7701-7).
(4) The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification Instructions 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. Complete a W-8 BEN if you are not a U.S. person. If a W-8 BEN is completed, your signature does not serve to certify this section.
AUTHORIZATION 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. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. I/We agree to the terms & conditions * By selecting “I/We Agree to the Terms & Conditions”, providing the “Signature of Individual” and submitting the application, you are signing this Application electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Application. By selecting "Submit" using any device, means or action, you consent to the legally binding terms and conditions of this Application. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and the Delaware State Police Federal Credit Union. Signature of Individual * Date *
