CU Use Only: Member name Opening Application Amended

Member#    Date

SafeAmerica Credit Union Master Membership Account Card

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FEDERAL NOTICE ABOUT ACCOUNT OPENING PROCEDURES: To help the government fight the funding of terrorism and moneylaundering activities, federal law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account. 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 may also ask to see your identifying documents, such as your driver’s license.

SafeAmerica Credit Union (“SafeAmerica”) policy requires one or two of the following forms of current primary identification: (a) Driver's License; (b) State-issued ID Card; (c) U.S. Passport; (d) Foreign Passport; or (e) U.S. Military Identification. If you provide only one form of current primary ID, also provide one of the following forms of secondary ID: (a) Employee ID; (b) Birth Certificate; or (c) Payroll Check Stub with Current Name, Address and SSN. If you do not present your identifying documents to a SafeAmerica representative, legible photocopies must be submitted by mail.

MEMBER INFORMATION Last Name
 First Name
MI
Residence Address
 City
 State
Zip
Postal Address (if different)
 City
 State
Zip
Home Phone
 Work Phone
 Email
Employer Name & City
Mother's Maiden Name
 SSN/TIN
 Birth Date
Primary ID: Type No. Issue Date Issue Place Expiration Date
Other ID: Type No. Issue Date Issue Place Expiration Date
Are you a senior foreign political figure or close associate of a senior foreign political figure?YesNo
Do you anticipate foreign wire transfer activity on accounts associated with this membership?YesNo
JOINT OWNER (OPTIONAL) If designated, all accounts under membership (other than IRA and fiduciary) will be joint with right of survrorship.
See Member Account Handbook.
Last Name
 First Name
 MI
Residence Address
 City
 State
Zip
Postal Address (if different)
 City
 State
Zip
Home Phone
 Work Phone
 Email
Employer Name & City
Mother's Maiden Name
 SSN/TIN
 Birth Date
Primary ID: Type No. Issue Date Issue Place Expiration Date
Other ID: Type No. Issue Date Issue Place Expiration Date
Are you a senior foreign political figure or close associate of a senior foreign political figure?YesNo
MEMBERSHIP ELIGIBILITY By applying for membership, you declare under penalty of perjury that you are eligible for SafeAmerica membership because you
work for or are retired from the following member company:
are related by blood, marriage, or adoption to the following SafeAmerica member:
  Member Name:Member Number:
  This member is the applicant's spouse   parent   child   sibling
live, work, attend school or worship in one of the following California counties:
    Alameda   Contra Costa   San Mateo   Santa Clara
If eligibility is through school attendance or worship, the name of the city of your school or place of worship is
ACCOUNT AUTHORIZATION You request that SafeAmerica open the following accounts. Your signature on this form is your continuing authorization to establish new share accounts under this membership upon your request and deposit of funds.
Account Type Opening Balance
Share Savings ($25 balance required for membership) $
Checking Dividend Advantage Free Senior (age 54+) $
Holiday Club $
High Yield Money Market $
Money Market $
Additional Savings $
Certificate ($1,000 minimum balance) months $
IRA (addittional application required) Traditional  Roth $
You do do not want your home number printed on checks $
ELECTRONIC SERVICE REQUESTS You request the following electronic services.
Online Banking (includes e-statements) Online Bill Pay
VISA® Debit Card (available only with checking) ATM Card (if no checking opened)
STARS Telephone Banking  Direct Deposit (additional form required)
By enrolling in Online Banking, you enroll in e-statements and receipt of other disclosures in electronic form. You will receive an e-mail notice when periodic statements or other disclosures are available for pickup on SafeAmerica's secure web site. If you prefer that SafeAmerica mail you paper statements, initial here
OVERDRAFT PROTECTION If I have a checking account, I request that SafeAmerica cover any overdrafting transactions from the following sources:
Share Savings Transfer VISA Credit Card Advance (separate application required) If you designate and are approved for more than one source, SafeAmerica can choose the order in which to access sources.

If you do not have approved and available overdraft protection form Share Savings or VISA Credit Card, SafeAmerica may, consistent with the terms of the Member Account Handbook, pay or return items that would overdraw your checking account, and charge the Credit Union's paid/returned NSF fee for doing so. Any negative balances that result from payment of NSF items may be recovered from your next incoming deposit(s) of funds or from other sources as specified in the Member Handbook. If you prefer that all items presented against insufficient funds be returned unpaid, initial here 

PAY ON DEATH BENEFICIARIES When all owners of the account are deceased, the following persons are to receive any remaining funds in accounts established under this membership (other than IRA or fiduciary), subject to SafeAmerica's right to recover your obligations to the Credit Union. Funds will be disbursed in equal shares unless a different percentage is indicated. Designation of eligible family members as beneficiaries may increase federal share beneficiaries, please request an additional form.

Name
Address		  

Social Security No.
Relationship to Member
%

Name
Address		  

Social Security No.
Relationship to Member
%
OTHER SERVICES You would like applications for the following additional services:
VISA Credit Card Vehicle Loan Mobile Home Loan Personal Loan
Home Purchase/Refinance Loan Home Equity Loan Home Equity Line of Credit (not available in Texas)
Other (describe):
GENERAL PROVISIONS By signing this application and submitting it to SafeAmerica, you confirm and/or agree: (1) The person identified as "Member," unless already a member, applies for SafeAmerica membership and acknowledges that if you provide false information about elibibility, your membership and all related services will be terminated. (2) You will abide by applicable laws and SafeAmerica's bylaws in all dealings with SafeAmerica. (3) You authorize SafeAmerica to check your credit and account history and verify information on this application. (4) Any designated joint owner is responsible, jointly and severally, with the member, for meeting account abligations to SafeAmerica. (5) You acknowledge receipt of the SafeAmerica Member Account Handbook applicable Truth in Savings Disclosure(s) and Fee Schedule and consent to their terms as amended from time to time upon legally sufficient notice. (6) Your faxed signature on any document you submit to SafeAmerica will have the same legal effect as your original signature. Any document you submit to SafeAmerica via a secure electronic channel will have the same legal effect as if it bears your original signature. (7) Information on your most recent Account Card in our records will be considered your current information and any information left blank will be considered to have been intentionally omitted. (8) If your application is not submitted in person, no transactions will be permitted other than the opening deposit until SafeAmerica receives the signed original Card and ID document copies. (9) If you become indebted to SafeAmerica in any way, including by you use of plastic cards or by overdrawing your checking account, and do not pay as agreed, SafeAmerica can take SafeAmerica shares in which you have an interest to recover all or part of your debt without notice and without waiving other collection rights. This consent applies to all funds voluntarily deposited by law or the share agreement. SafeAmerica never requires deposit of exempt funds. This consent is in addition to SafeAmerica's right to impress a lien on shares under CA Finan. Code Sec. 14856 or any equitable right to offset. (10) SUBSTITUTE W-9 TAXPAYER ID CERTIFICATION: YOU MY ASK A SAFEAMERICA REPRESENTATIVE FOR OFFICIAL IRS W-9 INSTRUCTIONS, OR, IF APPLYING ONLINE, GO TO WWW.IRS.GOV AND USE THE W-9 FORM LINK TO OBTAIN W-9 INSTRUCTIONS. YOU DECLARE UNDER PENALTY OF PERJURY THAT (A) YOU ARE U.S. PERSON (INCLUDING RESIDENT ALIEN); (B) THE TAXPAYER ID NUMBER PROVIDED ON THIS APPLICATION IS CORRECT; AND (C) EITHER (1) YOU HAVE NEVER BEEN NOTIFIED BY THE IRS THAT YOU ARE SUBJECT TO BACKUP WITHHOLDING DUE TO FAILURE TO REPORT DIVIDENDS OR INTEREST OR (2) YOU HAVE BEEN NOTIFIED BY THE IRS THAT YOU ARE NO LONGER SUBJECT TO BACKUP WITHHOLDING. THE IRS DOES NOT REQUIRE YOUR CONSENT TO ANY TERM OF AGREEMENT WITH SAFEAMERICA OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING. IF YOU ARE SUBJECT TO BACKUP WITHHOLDING, THE FOLLOWING BOX(ES) IS/ARE CHECKED:
 MEMBER  JOINT OWNER
Date Primary Member Signature
Date Joint Owner Signature