Richmond Community FCU
2048 Tobacco Road
Gracewood GA, 30812
  Share Draft #:
Deposit Account
My correct Taxpayer ID (Social Security) #
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, (2) I am not subject to backup withholding because: (a) I am exempt from 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. person (including a U.S. resident alien).

Instructions: Cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. Cross out item 3 and complete a W-8 BEN if you are not a U.S. person

Members Signature___________________________________Date

Member Information      I qualify for membership because
  Name         Date of Birth
Address           APT. #
      City              State             Zip
Home Phone   DL State                              Employer
  Work phone          DL # Employer #
Joint Member Information (Optional)
  Name       DOB
Address   APT. # SSN
      City      State   Zip
  Name         DOB
Address APT. #   SSN
      City   State       Zip

I Hereby make application for membership in and agree to conform to the Bylaws, as may be amended, of Richmond Community Federal CU ("Credit Union"). I certify that I am within the field of membership of this Credit Union; the SIGNATURES(S) on this card apply to all accounts designated above; and all information provided is true and correct. I also acknowledge that I have received and agree to be bound by the terms and conditions on this form and in the Accounts & Services of the Credit Union Booklet, Truth-in-Savings Act Rate and fee Schedule, and any Special Account or other separate Account Services Applications or Agreements as amended from time to time, which are incorporated herein by reference. All present and future deposits to the account(s) designated above secure payment of any account owner's obligations to the Credit Union. Further, I agree that the street and e-mail addresses above are publicly available and will be used by the Credit Union and certain third parties to provide notices, disclosures and other communications as explained in the Credit Union's Privacy Policy. The singular includes the plural as applicable herein. The Internal Revenue Service (IRS) does not require the applicant's consent to any provision of this document other than the certification required to avoid backup withholding previous mentioned above

If you wish to have a direct deposit into your savings or checking account, please complete and submit an authorization Agreement for Direct Deposit form along with this Membership Application.

Member's Signature________________________________________ Date
Joint Signature ___________________________________________
(with full right of survivorship)
Joint Signature____________________________________________
(with full right of survivorship)
Credit Union Only
Date Received
Date Fee Taken
Teller #
S/D Approval Date
2nd Chance ?
Family Member?
Primary Member #
Payroll Group #

You Must Print, Sign, and Return to Credit Union
(by mail, fax, or in person)

A signature is needed to complete the process

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Look under File menu, Click on Page Setup, then change margins to 0.2"