Trust Account Application Form - Lafayette Federal Credit Union Page 3
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3The Credit Union is hereby authorized to recognize any of the signatures subscribed hereto in payment
of funds or the transaction of business for this account. The Trustee and Co-Trustee(s) (if any) of this
account hereby agree that all sums (now or hereafter) paid into this Credit Union account shall be
subject to withdrawal by any of them, and they acknowledge and agree that their signature without their
respective designations as “Trustee” or “Co-Trustee” shall be a valid signature, and payment to any of
them shall be valid and discharge the Credit Union from any liability for such payment. It is further
understood that the Credit Union accepts no administrative responsibilities for the Trust other than those
spelled out on this account card.
I/we agree to conform to the bylaws and policies of the Credit Union and subscribe to at least one share.
I/We have received and agree to the terms and conditions of the Account Agreement, the Funds
Availability and Electronic Funds Transfer Agreements, the Disclosure and the Fee Schedules.
By signing this form, you acknowledge and consent to the following identity confirmation program:
•
We require an original, unexpired government-issued picture identification and a Social Security
Number or taxpayer identification number.
•
For non-U.S. persons we require one or more of the following:
1. A taxpayer identification number
2. A passport number and country of issuance
3. An alien identification card number
4. A number and country of issuance of any other government-issued document evidencing
nationality or residence and bearing a photograph or similar safeguard
•
If you are mailing this application, we require that you submit a notarized copy of your picture
identification.
•
We may verify any information provided by you, e.g., your credit or employment report.
•
We may also ask you to provide additional information that we need to verify your identity, and
for other purposes related to your membership.
•
Your signature on this form authorizes the Credit Union to keep a copy of any information you
provide to establish your identity.
Under penalties of perjury, I certify (1) that the number shown on this form is the correct Social Security
number (SSN) or taxpayer identification number (TIN) and (2) that this taxpayer is not subject to backup
withholding as a result of a failure to report all interest or dividends, or the Internal Revenue Service has
notified the taxpayer that he/she is no longer subject to backup withholding in opening this account.
The Internal Revenue Service does not require your consent to any provision of this document
other than the certification required to avoid backup withholding.
______________________________________________________
_______________
Trustee’s Signature
Date
______________________________________________________
_______________
Co-Trustee’s Signature
Date
For Credit Union Use Only.
__________________________________________________________
________________
Membership Officer
Date
261787 8/06 VI
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