EFTA00124680.pdf

CLUB ACCOUNTS • VACATION g HOLIDAY Account No. ▪ Transfer to Shares g Transfer to Shares g Single Account 0 Transfer to Checking o Transfer to Checking O Joint Act O Stay in K Stay in Member Name Social Security Numb Home Address Brooklyn NY City State Date of Birth Place of Birth Home Phone 2 NYSDL 11/0 ID Type ID Number ID Description ID Ext INFORMATION ON JOINT MEMBER Name Social Security Numb Home Address Work Phone Number City State Home Phone Employer Name ID Type ID Number ID Description ID Etc; The undersigned acknowledges receipt of a copy. and agrees to be governed by the rules and regulations of the Municipal Credit Union applicable to Vac: Club Accounts as now in effect and as amended from time to time. Under penalties of perjury, I certify (I) that the number shown on this form is my correct taxpayer identification number; and (2) that lam not s withholding either because I have not been notified that I am subject to backup withholding as a result of failure to report all interest or dividend Revenue Service has notified me that I am no longer subject to backup withholding. 01/21/09 SIGNATURE OF PRIMARY MEMBER DATE 01/21 /09 SIGNATURE OF JOINT MEMBER DATE EFTA00124680