Account signature card for a credit union membership, NYC DHS employee

EFTA00133756¶

PO Box 3205 Church Street Station New York, NY 10007 (212) 693-4900¶

ACCOUNT SIGNATURE CARD¶

Account Number:		Basis for Membership: Employee of the Ci				Amends Existing Information
Please tell us about yourself		Verification Issued By: NY				Gender: Male Mr. Female
Last Name		First Name				Middle Initial		Suffix
Date of Birth (MM/DD/YYY)		Social Security Number Mother's Maiden Name (mother's last name before marriage)				Phone Center ID (4-digits required)		Home Phone Number
House #		NS EW	Street Name	Street Type	NS EW	APT/ FL	APT/ FL#	BROOKLYN City	NY ST 11207-1012 Zip Code
MAILING ADDRESS (where to direct mail other than the home address)		If adding a PO BOX address, check here
House #		NS EW	Street Name	Street Type	NS EW	APT/ BOX	APT/ BOX#	City	ST Zip Code
NYC DHS Employer Name		officier Job Title		NYC Agency Seg. Group		718-363-4702 Work #
Cell/Mobile Phone Number		U.S. Person USA Citizenship	Gross Income/Month		3,500.00	20 Cash Deposit Amt/Month	0 #Incoming Wires/Month
Email Address		Re-Type Email Address (for verification)
NYS Learners Permit ID 1 Type		ID 1 Number		NYP Perm ID 1 Description		03/26/19 ID 1 Expiration Date
Job Identification ID 2 Type		ID 2 Number		NYC DHS ID 2 Description		06/30/20 ID 2 Expiration Date
Joint Account Holder		Verification Issued By:
Check if address same as Primary		Amends Existing Information Add Joint Account Holder
Last Name		First Name Middle Initial Suffix
Date of Birth (MM/DD/YYY)		Social Security Number Mother's Maiden Name(mother's last name before marriage) Phone Center ID(4-digits required) Home Phone Number
House #		NS EW	Street Name	Street Type	NS EW	APT/ FL	APT/ FL#	City	ST Zip Code
Employer Name		Job Title Seg. Group Work # Relationship to Primary Member
Cell/Mobile Phone Number		Citizenship Gross Income/Month Cash Deposit Amt/Month #Incoming Wires/Month
Email Address		Re-Type Email Address (for verification)
ID 1 Type		ID 1 Number ID 1 Description ID 1 Expiration Date
ID 2 Type		ID 2 Number ID 2 Description ID 2 Expiration Date

EFTA00133757¶

PO Box 3205 Church Street Station New York, NY 10007 (212) 693-4900¶

ACCOUNT SIGNATURE CARD¶

Beneficiary Information (optional) ✉ Check if address same as Primary¶

Last Name			First Name					Middle Initial		Suffix
Date of Birth			Social Security Number		Mother Relationship to Primary Member				347-985-3318 Home Phone Number
House #	NS EW	Street Name	Street Type	NS EW	APT/ FL	APT/ FL#	BROOKLYN City	NY ST	11207 Zip Code

I hereby apply for membership and subscribe for at least one share ($5.00) in the Municipal Credit Union and agree to conform to its By-Laws and amendments thereof. I agree to be governed by the Account Agreement, Rules and Regulations and Schedule of Dividends, Service Charges and Fees of the Municipal Credit Union applicable to Share, FasTrack Checking, Vacation, Holiday and Money Market accounts as now in effect and as from time to time amended. I agree to be bound by the terms and conditions of the MCU Cash Connection, MCU ATM/Check Card, MCU OnLine Banking, and Touch Tone Teller Agreements (which will be later mailed/provided to me), upon my first use of such service(s).¶

I understand that the designations made on this signature card/form will apply to all MCU deposit accounts which are or will be in the future maintained under the same root account number (except IRA, Youth Club, and Share Certificate accounts), and will have the effect of revoking all previous designations made with regard to such accounts.¶

If a joint tenant has been designated on this signature card, it is agreed that these accounts be payable to either of us and upon the death of one of us, to the survivor. Also, it is agreed that any joint tenant may, without the consent of or notice to the other, pledge all or any part of the shares in these accounts as collateral security for a loan with MCU. If a beneficiary (beneficiaries) has (or have) been designated on this signature card, it is agreed that this is a voluntary and revocable trust, and that upon my/our death, the funds in these accounts, and all other deposit accounts maintained under the same root account number (except IRA, Youth Club, and Share Certificate accounts), will become the property of the named beneficiary or beneficiaries who are alive at the time of my/our death in equal proportions. If both a joint tenant and a beneficiary (or beneficiaries) have been designated on this signature card, it is agreed that the beneficiary(ies) will only acquire an interest in these accounts upon the death of the last surviving joint tenant.¶

By signing below, I/We authorize Municipal Credit Union to perform a credit investigation including the verification of the information on this application. Verification of income and employment may also be required.¶

Under penalties of perjury, I certify (1) that the number shown on this form is my correct taxpayer identification number; and (2) that I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of failure to report all interest or dividends, or because the Internal Revenue Service has notified me that I am no longer subject to backup withholding; and (3) I am a U.S. citizen (including a U.S. resident alien). The Internal Revenue Service does not require your consent to any provision of this document other than the certification required to avoid backup withholding.¶

08/15/16¶

Date¶

Joint Account Holder Signature¶

Date¶

Yes, I elect to accept the Check Imaging option and agree to pay the associated service charge.¶

If Joint Account Holder requests an MCU ATM/Check Card, check this box.¶

Sponsor Account Number¶

Member Service Representative¶