337 N. Main, Sikeston, MO 63801
By typing my name below, I hereby certify that all statements made, on the entire form, are true and complete to the best of my knowledge and that I have read and agree to the Electronic Signature Terms.
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 Division 10 Highway Employees' Credit Union makes from time to time which are incorporated herein. I (we) have read 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.
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 and 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.
Special Instructions: To open an account, you will need to 1) complete the form below and 2) bring a deposit of $30.00 to the credit union and 3) pay a $1.00 (one-time) fee to open your account.