Synchrony Bank Guardianship/Conservatorship Certification Form

P.O. Box 105972, Atlanta, GA 30348-5972
Synchrony Bank Guardianship/Conservatorship Certification Form
Please complete the applicable sections below, sign before a notary and return BOTH pages to Synchrony Bank.
By signing this document, the Guardian/Conservator named below certifies and directs:
THIS FORM IS FOR THE FOLLOWING CUSTOMER:
Customer Name
Social Security Number
City
Customer Address
State
Zip Code
THE GUARDIAN’S/CONSERVATOR’S PERSONAL INFORMATION IS:
First Name
Last Name
Social Security Number
Date of Birth Country of Citizenship
Home Address (No P.O. Boxes please)
City
State
Zip Code Previous Address (If less than 5 years at above address)
City
State
Zip Code
Mailing Address (If different from above)
City
State
Zip Code
Home Telephone
Employer Name Years at Address
Email Address
Occupation
Driver’s License or other State ID Number
State of Issue
(1)Are there any other Guardians or Conservators serving?
YES
Business Telephone
Issue Date
Expiration Date
NO
If you answer yes, each Guardian or Conservator will need to complete a Guardianship/Conservatorship Certification Form and will be added to all of the customer’s accounts.
(2)The Court Order appointing you as Guardian or Conservator has not been revoked and is in full force and effect.
(3)You will refund to Synchrony Bank any amounts erroneously distributed from any of the customer’s accounts at any time.
(4)The customer named above is currently living.
(5)You will promptly notify Synchrony Bank: (a) if you are removed as the Guardian or Conservator of the customer; or (b) of the
customer’s death; and
(6)You, Individually and as the Guardian or Conservator for the customer named above, release, discharge, indemnify and hold
Synchrony Bank harmless against all claims, suits, causes of action, damages, losses, expenses, legal fees, costs and any other
liabilities that Synchrony Bank may be subject to as a result of, or in connection with, any transactions or instructions initiated or
provided by you with regard to the customer or any of the customer’s accounts.
© 2016 Synchrony Bank
GUARDIAN_CONSERVCERT_FORM
[REV. 01/2016]
1
SIGNATURE
x
Guardian/Conservator Signature
Print Name
NOTARY ACKNOWLEDGMENT
State of :
County of :
Sworn to and acknowledged before me, (Notary)
day of , 20
.
(Notary signature)
My Commission Expires:
GUARDIAN_CONSERVCERT_FORM
[REV. 01/2016]
2
, by the individual named above on this