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Membership, Accounts & Services Application

Account Information
* Required Fields
Account Types:
Account Ownership:
Joint Account: If You are establishing a Joint Account, please check only one box below and sign where applicable
Joint Account:

IMPORTANT INFORMATION ABOUT PROCEDURE[S] FOR OPENING A NEW ACCOUNT

To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an Account.

What this means for You: When You open an Account, We will ask You for Your name, address, date of birth, and other information that will allow Us to identify You. We may also ask to see Your driver’s license or other identifying documents.

Membership Eligibility
I am eligible for PTOFCU membership through:
Primary Owner Name
Date of Birth:
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Social Security Number:
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Joint Owner Name
Date of Birth:
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Social Security Number:
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ATM Card/VISA Check Card/Audio Response/Online Teller/Mobile Banking
You are requesting the convenience of 24-hour access to Your Credit Union Account in conjunction with a Personal Identification Number (PIN) or Access Code. Your VISA Check Card will allow You to use a number of Automated Teller Machine (ATM) networks, including the Credit Union’s ATM machines and will also allow You to pay for services and purchases directly from Your linked account. You would like:
Payable-On-Death Account Beneficiary Designation
In the event of Your death, You hereby designate the following beneficiary(ies).
Date of Birth:
 /   / 
Social Security Number:
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Date of Birth:
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Social Security Number:
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Date of Birth:
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Social Security Number:
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Taxpayer Identification & 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) the FATCA code entered on this form (if any) indicating that the payee is exempt from FATCA reporting is correct.
 
 
Credit Union Use Only
Verification List(s) Checked:
Reports Checked:

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.

Foreign Person. If You are not a U.S. person and are a foreign person, do not use this certification. Instead, use Form W-8BEN - Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding and Reporting (Individuals).

Signatures

You hereby apply for membership with Patent & Trademark Office Federal Credit Union. You warrant the truth of the information contained in Your application for membership and/or in subsequent representations to Us. You realize that such information will be relied upon by Us in determining Your membership eligibility. You hereby authorize Us, Our employees and agents to investigate and verify any information provided to Us by You. By signing below, You agree to be bound by the terms and conditions found within Your application for membership and to the bylaws, rules and regulations of Patent & Trademark Office Federal Credit Union in effect from time to time. You further acknowledge receiving a copy of the Agreements and Disclosures related to Your Account(s) and You agree to be bound by the terms and conditions found therein. If Your application for membership is a joint application, any liability created by the use of Your Account is joint and several. You authorize any person, association, firm, corporation or personnel office to furnish information concerning Your affairs upon Our request, including, but not limited to, providing credit and employment history information. In addition to establishing a primary Savings Account, You may also from time to time request additional Accounts and/or Account Services be established on Your behalf and/or the addition of joint owner(s) of Your Account(s). Your signature below is Your continuing authorization for Patent & Trademark Office 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 herein in the payment of funds or the transaction of any business for Your Account(s).

The Internal Revenue Service does not require Your consent to any provision of this document other than the certifications required to avoid backup withholding

Date Signed:
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Date Signed:
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Security Code:

  Membership Account Disclosure