Membership Application

Application Requirements

Applicant Information

Tin Certification

Authorization

Application Requirements

Eligibility
- Are your eligible *
  I live, work, or worship in LaPorte County. I am a family member of a current LaPorte CFCU member.
- How did you hear about us? *
  Friend/Family Newspaper Internet Magazine Other
Application Type
- Individual Account * Joint Account
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 $25.00 membership balance.
- Additional Accounts *
  Share/Savings Account Share/Draft Checking Business Special Share Christmas Club Vacation Club Savvy Savers Kids Club Round Up Savers
Applicant Information
- Name *
- Address *
- City *
- State *
- Zip *
- Home Phone *
- Cell Phone
- Work Phone *
- Social Security Number *
- Drivers License State *
- Drivers License Number *
- Drivers License Expiration Date *
- Date of Birth *
- Email
- Employer *
- Position/Title *
- Length of Employment *
- All members will have to present 3 forms of id to open account (ID, SOC, credit card or birth cert) and a signature will be required to complete the enrollment
Emergency Contact
- Name *
- Address *
- City *
- State *
- Zip *
- Phone *
Beneficiary Informtion

The owners of many accounts name payable-on-death (POD) beneficiaries for the accounts. That means that when the account owner (or the last surviving owner, in the case of a joint account) dies, the POD beneficiary can simply claim the money from the Credit Union. The deceased person's will does not come into play, and there's no need for any probate court involvement, either.

POD designations are widely used because they're simple both for the person who sets them up and the beneficiaries who inherit. Please indicate below if you would like to include a beneficiary at this time.
- Would you like to designate a beneficiary? *
  Yes I do not wish to name a beneficiary at this time
Beneficiary #1
- Beneficiary First Name
- Beneficiary Last Name
- Beneficiary Relationship
- Beneficiary Address
- Beneficiary Address 2
- Beneficiary City
- Beneficiary State
- Beneficiary Zip
- Beneficiary Social Security Number
- Beneficiary Date of Birth
Beneficiary #2
- Beneficiary First Name
- Beneficiary Last Name
- Beneficiary Relationship
- Beneficiary Address
- Beneficiary Address 2
- Beneficiary City
- Beneficiary State
- Beneficiary Zip
- Beneficiary Social Security Number
- Beneficiary Date of Birth
Beneficiary #3
- Beneficiary First Name
- Beneficiary Last Name
- Beneficiary Relationship
- Beneficiary Address
- Beneficiary Address 2
- Beneficiary City
- Beneficiary State
- Beneficiary Zip
- Beneficiary Social Security Number
- Beneficiary Date of Birth
Beneficiary #4
- Beneficiary First Name
- Beneficiary Last Name
- Beneficiary Relationship
- Beneficiary Address
- Beneficiary Address 2
- Beneficiary City
- Beneficiary State
- Beneficiary Zip
- Beneficiary Social Security Number
- Beneficiary Date of Birth
Beneficiary #5
- Beneficiary First Name
- Beneficiary Last Name
- Beneficiary Relationship
- Beneficiary Address
- Beneficiary Address 2
- Beneficiary City
- Beneficiary State
- Beneficiary Zip
- Beneficiary Social Security Number
- Beneficiary Date of Birth
Joint Applicant
- Name *
- Address *
- City *
- State *
- Zip *
- Home Phone *
- Cell Phone
- Work Phone *
- Social Security Number *
- Drivers License State *
- Drivers License Number *
- Drivers License Expiration Date *
- Date of Birth *
- Email
- Employer *
- Position/Title *
- Length of Employment *
- All members will have to present 3 forms of id to open account (ID, SOC, credit card or birth cert) and a signature will be required to complete the enrollment
TIN certification and backup withholding information

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 301.77701.7).
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification Instructions.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 Agreement

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.

To complete the account opening process, you must stop by a La Porte Community FCU location with your government-issued photo ID.
I will complete my account opening at
As part of the account opening process, La Porte Community FCU will obtain information about you from a consumer reporting agency. Based on that information, you may or may not be approved to open the account. I authorize La Porte Community FCU to access consumer reports for me and any joint applicants in order to process this application.
- Primary Applicant Date *
- Joint Applicant Date *

Application Requirements

Eligibility

Application Type

Account Type

Applicant Information

Emergency Contact

Beneficiary Informtion

Beneficiary #1

Beneficiary #2

Beneficiary #3

Beneficiary #4

Beneficiary #5

Joint Applicant

TIN certification and backup withholding information

Authorization Agreement