(800) 226-6673
Office Use Only
MSR Name: ______________________
Document Type: Account Change Form
Date processed ____________________
PUBLIX EMPLOYEES FEDERAL CREDIT UNION
ACCOUNT CHANGE FORM
This form may be used to change your name or to remove a joint owner from any of your existing accounts. Complete only the
applicable portions of this form.
If not appearing in person, mail to the nearest PEFCU branch office with a photo copy of your identification. Identification
accepted: Valid Driver’s License or State ID. This form will not be processed without proper identification.
NAME: ______________________________ ACCOUNT # __________________________
DATE: __________________________
□
CHANGE NAME
- In addition to your photo ID, proof of the name change must be submitted by providing a copy of your new social
security card, court order OR marriage license.
Please change my name from ___________________________________________ to ______________________________________.
□ I currently have a Visa Checkmate Debit, PEFCU ATM, and/or Visa Credit Card. By initialing below I agree to the Governing law and
terms and conditions on my original Debit, ATM and/or Credit Card application(s). I request the card(s) to be reissued in my new name.
Initials required next to the card(s) being replaced.
_________ Visa Checkmate card
_________ PEFCU ATM card
__________ Visa Credit Card
□ Additional account number(s) ____________________________________
□ I would like to order a box of checks in my new name. (Check fees apply.)
□ I have a Safe Deposit Box and need the additional documentation to change my name on the box.
□ I have an IRA and need the additional documentation to change my name on the IRA account.
□
REMOVE JOINT OWNER (
Funds will be withdrawn from the above mentioned account number. It will be closed and reopened in my
name only. I take full responsibility of the account from this point forward. All additional owners on the account must also sign this form.)
Please remove __________________________________________________________________________ from my account.
□ Savings/Club accounts
□Checking
□ Money Market
Remove joint owner from:
□ I would like to order a box of checks in my name only. (Check order fees apply.)
REQUIRED SIGNATURE(S)
By Signing this form I agree to the terms and conditions found in the “Important Account Information” Brochure and the Governing Law on
my original Membership, Checkmate Debit, ATM, and/or Visa Credit Card application(s).
Owner signature: _________________________________________ Owner signature: ________________________________________
Owner signature: _________________________________________ Owner signature: ________________________________________
Rev. 9/15