Account Change Form - Police and Fire Federal Credit Union

Account Change Form
MEMBER NUMBER
EFFECTIVE DATE
CHANGE OF ADDRESS
ADD/CHANGE BENEFICIARY
ADD JOINT OWNER
REMOVE JOINT OWNER/BENEFICIARY
NAME CHANGE
ADD AUTHORIZED SIGNER
REMOVE AUTHORIZED SIGNER
SHARE TYPE/SERVICE _______________
ACCOUNT NAME
PHYSICAL ADDRESS
CITY
STATE
ZIP
MAILING ADDRESS (IF DIFFERENT)
CITY
STATE
ZIP
HOME PHONE
JOINT OWNER #1 NAME
MOBILE PHONE
EMAIL ADDRESS
STREET
JOINT OWNER #2 NAME
STREET
EMAIL ADDRESS
S.S. #
CITY
EMAIL ADDRESS
STATE
S.S. #
CITY
STATE
DOB
DRIVERS LICENSE NO./STATE/EXP./ISS.
ZIP
EMPLOYER/OCCUPATION
DOB
DRIVERS LICENSE NO./STATE/EXP./ISS.
ZIP
EMPLOYER/OCCUPATION
Add/Change Account Beneficiary Designation
BENEFICIARY
RELATIONSHIP
S.S. #
DOB
PCT
BENEFICIARY
RELATIONSHIP
S.S. #
DOB
PCT
Authorized Signers
AUTHORIZED SIGNER
POSITION/TITLE
DRIVERS LICENSE NO./STATE
SIGNATURE
AUTHORIZED SIGNER
POSITION/TITLE
DRIVERS LICENSE NO./STATE
SIGNATURE
Signatures
You hereby authorize Police and Fire Federal Credit Union to make the changes to Your Account as designated herein. If You are being added to an Account, by signing below, You
agree to be bound by the terms and conditions found within Our Agreements and Disclosures. You acknowledge receiving a copy of those Agreements and Disclosures related to Your
Account(s) and You agree to the terms and conditions found therein. You further agree to be bound by the bylaws, rules and regulations of the Credit Union in effect from time to time.
You hereby authorize Us, Our employees and agents to investigate, verify and update at any time (both now and in the future) any information provided by You to Us. You further
authorize any person, association, firm, corporation or personnel office to furnish information about You upon Our request, including, but not limited to, providing credit and employment
history information. You may also from time to time request additional Accounts and/or Account Services to be established on Your behalf and/or the addition of joint owner(s) of Your
Account(s). If You are designating an authorized signer, You understand that unless We receive written instructions to the contrary, such individuals are authorized to deposit and
withdraw funds from each Account designated herein and transact any other business related to such Accounts now or in the future, and We are further authorized to pay out funds
and/or transact any other business related to such Accounts with any one of those individuals. Your signature below is Your continuing authorization for Police and Fire Federal Credit
Union to follow Your written or verbal instructions to do so and You agree that Your continuing authorization will remain in effect unless We receive written instructions to the contrary.
You hereby authorize Us to recognize any of the signatures subscribed below in the payment of funds or the transaction of any business for Your Accounts.
The Internal Revenue Service does not require Your consent to any provision of this document other than the certifications required to avoid backup withholding.
Account Holder’s Signature
Date
Joint Owner #1 Signature
Date
Copyright Oak Tree Business Systems, Inc., 2014. All Rights Reserved.
Joint Owner #2 Signature
Page 1 of 2
Date
OTBS 014A PFFC (3/14)
Taxpayer Identification and Backup Withholding
Under penalties of perjury, You certify: (1) that the number shown on this form is Your correct taxpayer identification number (or the minor beneficiary's correct taxpayer identification
number if the Account is established under the Uniform Gift/Transfer to Minors Act); (2) that You are not subject to backup withholding either because You have not been notified that
You are subject to backup withholding as result of a failure to report all interest dividends, or the Internal Revenue Service (IRS) has notified You that You are no longer subject to backup
withholding; (3) You are a U.S. person (including a U.S. resident alien); and (4) You are exempt from FATCA reporting.
INSTRUCTION TO SIGNER. If You have been notified by the Internal Revenue Service (IRS) that You are subject to backup withholding due to payee underreporting and You have not
received a notice from the IRS that the backup withholding has terminated, You must strike out the language in part (2) of the statement above.
DO NOT STRIKE OUT ANY MATERIAL UNLESS YOU ARE SUBJECT TO BACKUP WITHHOLDING BY THE FEDERAL GOVERNMENT.
We will be unable to open an Account for You without a taxpayer identification number.
For Credit Union Use Only:
Membership Officer: ________________________________
_____________________________OFAC
Date ________________________________ Updated By ___________________________________ Member Verification __________________________________
Copyright Oak Tree Business Systems, Inc., 2014. All Rights Reserved.
Page 2 of 2
OTBS 014A PFFC (3/14)