EFTA00133749 ## Page 1 ## Member Name Information:
Title:
First Name:
Middle Name:
Last Name:
Suffix:
Name Format:
Preferred Contact:No.
Home Phone:
Work Phone:
Work Phone Ext:
Mobile Phone:
Phone Type:Domestic
Pager Number:
E-Mail Address:
Alt E-Mail Address:
Preferred Contact Method:Not Specified
DBA Title:
DBA First Name:
DBA Middle Name:
DBA Last Name:
DBA Suffix:
DBA Name Format:Individu
## Military APR Information:
Active Duty:Not in Active Duty Service
Active Duty Verification Date:___/___
Active Duty Start Date:___/___
Active Duty Separation Date:___/___
## Member Address Information:
Address Type:Domestic address
Street:2027 85TH ST
City:BROOKLYN
State:NY
Zip Code:11214
## Name Record Information:
MBR Number Link:
MBR Number Link Chg Date:/ / /
License:
Address Verify Date:/ / /
Mail Override:No override
ECOA Code:Individual
Beneficiary Percent:0.000%
Extra Information:
SSN Change Date:/ / /
SSN/TIN Override:No override
SSN/TIN Certification:Not certified
IRS Correction:No Correction
Amendment Number:0
Credit Report Consumer Info:
Credit Rpt Consumer Date:/ / /
Use as Marketing Address:No
Identification 1:
Documentary Flag 1:Documentary Identification
ID Type 1:State Drivers License
ID Description 1:
09/04/2019 | Description | Value | | :--- | :--- | | Birth Date: | | | Death Date: | | | Sex: | | | Mother's Maiden Name: | | | SSN/TIN: | | | SSN/TIN Type: | Individual SSN | | U.S. Person Flag: | U.S. Person | | Current Employer: | | | Occupation: | | | Curr Gross Mo Pay: | 0.00 | | Curr Net Mo Pay: | 0.00 | | Curr Mo Pay Last Updated: | __/___ | | Restricted Access: | Normal | | MBR Status: | Non Member |
FinCEN Information:
CTR Exempt:Not Exempt
Legal Entity Identifier:
Beneficial Owner Type:None
Beneficial Owner Percentage:0.000%
## Nonresident Alien Reporting:
IRS Country Code:
NRA Tax Rate:30.000%
NRA Exemption Code:
Form W-8 On File:No
W-8 Expiration Date:/ / /
Foreign TIN:
Chapter 4 Status Code:23
GIIN:
Substantial Owner:No
LOB Code:
Extra Address:
Country:
Country Code:
Carrier Route:
ADDR Number Link:
ADDR Number Link Chg Date:/ / /
Copy other Name:
Name Type:Beneficiary
Name SubType:0
Name Change Date:09/25/2007
Address Change Date:09/25/2007
Credit Rpt Address Change Date:09/25/2007
Effective Date:/ / /
Expiration Date:/ / /
Last FM Date:09/25/2007
MBR Last FM Date:/ / /
ADDR Last FM Date:/ / /
Confidential:Unclassified
Credit Rpt Address Indicator:
CR Address Indicator Date:/ / /
Identification 2:
Identification 2:
Documentary Flag 2:Non-documentary Identification
ID Type 2:Unknown
ID Description 2:
EFTA00133750 ## Page 2 ID Number 1: ID Issuance Date 1: ID Expiration Date 1: ID Verification Date 1: 09/04/2019 ## Identification 3: Documentary Flag 3: ID Type 3: ID Description 3: ID Number 3: ID Issuance Date 3: ID Expiration Date 3: ID Verification Date 3: **Custom Fields:** Membership Card Order: MIP Verified: Place of Birth: Relation to Primary/Joint: ID Number 2: ID Issuance Date 2: ID Expiration Date 2: ID Verification Date 2: Non-documentary Identification Unknown