Membership Application

Application Requirements

Applicant Information

Tin Certification

Authorization

* Indicates Required

Application Requirements

Eligibility

Are you eligible *
I live, work, worship, attend school, or volunteer in the Illinois counties of Bond, Calhoun, Clinton, Greene, Jersey, Macoupin, Madison, Monroe, Montgomery, or St. Clair. I am a family member of a current Midwest Members CU member. I am an employee of a select employee group affiliated with Midwest Members CU.
Whether you are eligible is required

How did you hear about us? *
Friend/Family Newspaper Internet Magazine Other
How you heard about us is required

Application Type

Application Type
Individual Account * Joint Account
Application type is required

Account Type

All of the terms, conditions, form of account ownership, account selection and other information indicated on this card apply to all of the accounts listed unless the Credit Union is notified in writing of a change. All accounts require a share/savings account with a minimum $5.00 membership balance.

Additional Accounts *
Share/Savings Money Market Share Certificate Christmas Club Vacation Club Basic Checking
At least one account type is required
Applicant Information

Name *

Address *

City *

State *

Zip *

Primary Phone *

Work Phone *

Social Security Number *

Driver's License Number *

Driver's License State *

Date of Birth *

Email *

Employer *

Joint Applicant

Name *

Address *

City *

State *

Zip *

Primary Phone *

Work Phone *

Social Security Number *

Driver's License Number

Driver's License State

Date of Birth *

Email

Employer *
Tin Certification and Backup Withholding

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), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person. For federal tax purposes, you are considered a U.S. person if you are: an individual who is a U.S. citizen or U.S. resident alien; a partnership, corporation, company, or association created or organized in the United States or under the laws of the United States; an estate (other than a foreign estate); or a domestic trust (as defined in Regulations section 301.7701-7).
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification Instructions.

Backup Withholding Agreement I have been notified by the IRS that I am currently subject to backup withholding because I have failed to report all interest and dividends on my tax return.

Complete a W-8 BEN if you are not a U.S. person. If a W-8 BEN is completed, your signature does not serve to certify this section.
Authorization

By signing below, I/we agree to the terms and conditions of the Membership and Account Agreement, Truth-in-Savings Disclosure, Funds Availability Policy Disclosure, if applicable, and to any amendment the Credit Union makes from time to time which are incorporated herein. I/We acknowledge receipt of a copy of the agreements and disclosures applicable to the accounts and services requested herein. If an access card or EFT service is requested and provided, I/we agree to the terms of and acknowledge receipt of the Electronic Fund Transfers Agreement and Disclosure. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

Primary Applicant Date *

Joint Applicant Date *

Additional Comments

Online Banking

Application Requirements

Eligibility

Application Type

Account Type

Applicant Information

Joint Applicant

Tin Certification and Backup Withholding

Authorization

Important Information About Procedures for Opening a New Account