Great Horizons Federal Credit Union
Membership Application
MEMBER APPLICATION AND OWNERSHIP INFORMATION
Account Number: office use only
Member/Owner:
Street:
City/State/Zip:
Home Phone:
Work Phone:
Employment:
Membership Eligibility:
E-mail:

SSN/TIN:

Driver's Lic. No.:
Driver's Lic. State:
Date of Birth:
ACCOUNT OWNERSHIP
Joint Owner:
Street:
City/State/Zip:
Home Phone:
Work Phone:
SSN/TIN:
Driver's Lic. No.:
Driver's Lic. State:
Date of Birth:
Employment:
BENEFICIARY DESIGNATIONS
Beneficiary/Payee:
Street:
City/State/Zip:
BACKUP WITHHOLDING CERTIFICATIONS
TIN:

CERTIFICATION. - Under penalties of perjury, I certify that:

(1) the number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), AND

(2) I am not subject to backup withholding either because I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholdings a result of a failure to report all interest or dividends, or the IRS has notified me that I am no longer subject to backup withholding (does not apply to real estate transactions, mortgage interest paid, the acquisition or abandonment of secured property, contributions to an individual retirement account (IRA), and payments other than interest and dividends), AND

(3) I am a U.S. person (including a U.S. resident alien)

CERTIFICATION INSTRUCTIONS. You must un-select option(2) above if you have been notified by the IRS that you are currently subject to backup withholding because of underreporting interest or dividend on your tax return. I have read and understand all disclosures.

By clicking the button, you are agreeing to the entire contents of this form.

Signature - I certify under penalties of perjury the statements checked in this section.

APPLICANT'S SIGNATURE AND DATE

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