Youth Member Application
PO Box 978, Frankfort, KY 40602-0978
800.228.6420 / 502.564.4775 www.ccuky.org
Type of Account:
Individual Account
Joint Account
Purpose of Account:
Application for Membership ($5 Deposit is REQUIRED)
Qualification For Membership
Account Type:
Ready Access
Qualified Through:
High Yield
Employer:
Related to someone who is eligible to join
Relative's Name:
Relative's Employer:
We reserve the right to verify this information.
Along with your $5 or more deposit, please include 1) An official ID (such as a copy of a driver’s license, state issued birth certificate, passport, student
ID, or state-issued ID card) with an address matching the information given below, AND 2) a copy of your parents utility bill with matching name and
address AND the company name plainly visible.
Name:
Home Address:
State: KY
Zip:
City:
State: KY
Zip:
Home Phone:
Work Phone:
Mobile Number:
Fax Number:
Social Security #:
Birth Date:
Drivers License #:
Drivers Lic. Exp:
Drivers Lic. Issue Date:
Email:
City:
Mailing Address:
Joint Owner Information
Name:
Home Address:
State: KY
Zip:
City:
State: KY
Zip:
Home Phone:
Work Phone:
Mobile Number:
Fax Number:
Social Security #:
Birth Date:
Drivers License #:
Drivers Lic. Exp:
Drivers Lic. Issue Date:
Email:
City:
Mailing Address:
Open Additional Accounts
Ready Access Savings
Vacation Club
High Yield Savings
Christmas Savings
Payroll Deduction:
Total Dollar Amount:
Each Check
Amount
Distributions:
Checking Account
Monthly
Member # - Share
RoundUP
Global Debit Card
PhotoCard
Your ATM/Global Card Personal Identification Number (PIN) will be assigned to you.
Overdraft Protection
I WANT Overdraft Protection
In case I overdraw my Checking Account, Please transfer funds (Choose up to 3 Accounts)
My Own Account(s)
Ready Access
High Yield
Other Savings/Checking ID #
High Yield
Other Savings/Checking ID #
High Yield
Other Savings/Checking ID #
Other Account/Member #
Ready Access
Other Account/Member #
Ready Access
I DO NOT Want Overdraft Protection
Have you lived at your present address for the past 2 years?
Previous Address:
Have you ever had a checking account with CCU before?
Account Number:
Yes
No
In what country are you a citizen?
United States
Other
Are you or any of your relatives or associates connected to
the government of a country other than the United States?
Yes
No
If Yes, What Country:
What types of items do you expect to be deposited to the account:
Cash
Checks
Direct Deposit
Wires
Other:
How frequently will deposits be made?:
How much will you be depositing per month?
Cash:
Foreign Wires:
Domestic Wires:
ACH:
How much will you be withdrawing per month?
Cash:
Domestic Wires:
Foreign Wires:
ACH:
Yes
Will the transaction involve countries other than the United States?:
No
If yes, list the primary country:
TIN CERTIFICATION & BACKUP WITHHOLDING INFORMATION
By signing below, I certify under penalties of perjury that: (1) I am a US Citizen or other US person, (2) the Taxpayer Identification Number (TIN)/Social Security
Number (SSN) shown is my correct identification number and (3) I am NOT, unless designated below, subject to backup withholding because I am exempt or I have
not been notified by the IRS that I am subject to backup withholding as a result of failure to report all dividends or interest, or because the IRS has notified me that I
am no longer subject to backup withholding.
I am subject to backup withholding
I am NOT a United States citizen or U.S. person (complete W-8BEM form)
Exempt
I acknowledge at the time of this application I voluntarily provided Commonwealth Credit Union, Inc. (“Credit Union”) with the above information qualifying me for
membership and I understand that the Credit Union is relying on this information. I certify, based on the above information, that I am qualified to be a member of this
Credit Union. I ALSO CERTIFY UNDER PENALTY OF LAW THAT MY SOCIAL SECURITY NUMBER OR TAX IDENTIFICATION NUMBER IS TRUE AND
CORRECT. These funds are held jointly with right of survivorship if the account is a joint account. I acknowledge receipt of and accept all disclosures of the services
for the above account. All policies are subject to change without notice. I authorize the Credit Union to obtain a credit report on me.
I grant to you a security interest and consensual lien in and to ALL SUMS ON DEPOSIT (except an IRA) in the Credit Union, to secure all of my obligations to the
Credit Union. “All sums on deposit” and “shares’ for purposes of this pledge means all deposits in any share savings, share draft, club, certificate, P.O.D., revocable
trust or custodial (s) accounts, whether jointly or individually held, that you have on deposit now or in the future. In case I default, you may apply these shares and
deposits to the payment of all sums due at the time of default. I acknowledge the Credit Union’s statutory lien pursuant to KRS 286-6.395 and rights to set-off, which
gives you the right to apply the sums in my account(s) to satisfy any obligations I owe to the Credit Union, regardless of contributions at the time of default, ALL without
further notice to me or any owner of the account(s). I further acknowledge the Credit Union’s right to set-off pursuant to KRS 391.355, which authorizes you to set-off
funds against my account(s) in which I or a co-owner have or had immediately before my death a present right of withdrawal without the joinder of any other party,
without further notice to me or any owner of the account(s).
I specifically agree that you have a right to place an administrative freeze on any of my joint or individual account(s) and that such action shall not violate 11 U.S.C. 362
or other applicable law.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
To help the government fight the funding of terrorism and money laundering activity, 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 for your name, address, date of birth
and other information that will allow us to identify you. We will also ask to see your driver's license or other identifying documents.
Signature:
Date:
Form Version 1.3