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¶