Revised:
ACCOUNT CARD Name Change ____________
1444 E. Sunshine Ownership Change ________
Springfield, MO 65804 Beneficiary Change ________
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.
Share/Savings Kasasa Cash
Checking: ____________________
MEMBER APPLICATION AND OWNERSHIP INFORMATION
I elect to have my Account Disclosure and Privacy Policy sent:
___Email ___ Website ___ Mailed ___ In Person Member No:
Member/Owner:
Holtz
Last___________________________ Andria
First _____________________ Ares
M.I.__________
Street:________________________________ Beach, 267-51-6862
4701 N Meridian Ave Ph L1 MiamiSSN/TIN:________________________
FL 33140
City/State: Miami Beach FL 33140
_________________________________________Zip:________________
H432-001-60-957-0
Driver’s Lic. No:_____________________________________ FL
State: _____________
12/17/1960
Date of Birth:___________________________ (470) 113-3140
Cell Phone:_____________________
(470) 113-3140
Work Phone:__________________________ (470) 113-3140
Home Phone:_____________________
andriaholtz1960@outlook.com
Email:________________________________________________________________
Cheese@6969
Acct. Password: _______________________________________________________
Please select one: ___Mercy Employee ___Mercy Affiliate ___ Family Member
Artemis Diane Ares
Mercy Facility/Family Member________________________ Lawson #: ____________
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 purpose, 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.
Certification 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. 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.
Exempt payee code (if any)______ Exemption from FATCA reporting code (if any) ________
AUTHORIZATION
By signing below, 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 have received and 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.
08/28/2025
X___________________________________________________________________________________
Primary Signature Date
X________________________________________ X____________________________________________
Joint Signature Date Joint Signature Date
2
Page 1 of ___
ACCOUNT SERVICES
*Please initial next to all services being declined at this time.
ATM Card ____________ Overdraft Protection ________________
Debit Card ____________ Courtesy Pay _____________________
Checks ______________ Home Banking ____________________
E-Statements __________
ACCOUNT OWNERSHIP
Designate the ownership of the accounts and responsibility for the services requested.
___ Individual ___ Joint Account with Rights of Survivorship
Joint Owner:__________________________________________________________
Street:________________________________ SSN/TIN:________________________
City/State: _________________________________________Zip:________________
Driver’s Lic. No:_____________________________________ State: _____________
Date of Birth:___________________________ Cell Phone:_____________________
Work Phone:__________________________ Home Phone:_____________________
Email:________________________________________________________________
Joint Owner:__________________________________________________________
Street:________________________________ SSN/TIN:________________________
City/State: _________________________________________Zip:________________
Driver’s Lic. No:_____________________________________ State: _____________
Date of Birth:___________________________ Cell Phone:_____________________
Work Phone:__________________________ Home Phone:_____________________
Email:________________________________________________________________
ACCOUNT DESIGNATIONS
Payable on Death (POD)/Trust Account
All Accounts Designate Specific Accounts: ____________________________
Beneficiary/POD Payee Beneficiary/POD Payee
Name:______________________________ Name:____________________________
Street: _____________________________ Street:____________________________
City/State/Zip: _______________________ City/State/Zip: ______________________
Date of Birth: ________________________ Date of Birth: ______________________
Relationship: ________________________ Relationship: ______________________
MTML (as custodian for _____________________(minor) under the Missouri
Transfer to Minors Law) Minor’s SSN/TIN:__________________________________
Agency Name of Agent: __________________________________________
Signature:__________________________ Date: _______________
All Accounts Designate Specific Accounts________________
Personal Custodian Account (as custodian for _____________________.)
Other: ___________________________________
FOR CREDIT UNION USE ONLY
Date of Membership: ________ Card Sent by: ______ Date: ______
Opened/Approved by: ______ Member Verification: _________ 2
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