Membership Application and Account Authorization
________________________________________________________________________

Join VACU by filling out our on-line Membership Application, print, and sign where indicated. Please provide all of the requested information.
You may submit your Membership Application by mail: Member Service, V A Credit Union, P.O. Box 21207, Wichita, KS 67218-7207, or in person at 804 S. Oliver. If by mail, please include your check for $27.00, proof of eligibility (a copy of your badge or enrollment ID card, etc) and a copy of your driver’s license.

1.Account Types/Services

2.TIN Certification and Backup

Under the penalties of perjury, I certify that:

The Social Security Number (SSN)/Taxpayer Identification Number (TIN) shown is my/the correct identification number, and
I am NOT, unless designated below, subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service that I am subject to backup withholding as a result of a failure to report all dividends of interest, or (c) the IRS has notified me that I am no longer subject to backup withholding.

Certification Instructions: You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because of underreporting interest or dividends on your tax return.

3.Membership Application and Information

First Name
MI
Last Name
Social Security #
Drivers Lic No
Street Address
Date of Birth
Mother’s Maiden Name (Name of Mother before Marriage)
City
State
Zip
Home Ph #
Work Ph #
Employer
Eligibility for Membership

4.Account Ownership

Designate the ownership of the accounts and responsibility for the services requested

	Single Party
	Joint-With Survivorship
	Trust-Separate Agreement date

Joint Owner Name
MI
Last Name
Social Security #
Drivers Lic #
Street Address
Date of Birth
Mother’s Maiden Name (Name of Mother before Marriage)
City
State
Zip
Home Ph #
Work Ph #

Joint Owner Name
MI
Last Name
Social Security #
Driver’s License #
Street Address
Date of Birth
Mother’s Maiden Name (Name of Mother before Marriage)
City
State
Zip
Home Phone #
Work Ph #

5. Account Designations

I/we being owner(s) of shareholder Account No. in the Veterans Administration Credit Union, do hereby revoke any former Contract for Designation of Beneficiary on Payable on Death Shareholder Account, if any, heretofore made for the Account number . I/we do hereby contract with the Credit Union that any money in my/our account at the time of my/our death shall be payable to:

1. Beneficiary
Name
Soc Sec #
Address
Relation to Member
Ph #
2. Beneficiary
Name
Soc Sec #
Address
Relation to Member
Ph #
3. Beneficiary
Name
Soc Sec #
Address
Relation to Member
Ph #

equally, hereinafter, referred to as the beneficiary or beneficiaries, as the case may be and if there is a claim pursuant to K.S.A. 39-709(g) and amendments thereto (assignment of rights to the State of Kansas for reimbursement of receiving medical assistance in which federal funds are expended), until such claim is satisfied.

I/we retain the right during my/our lifetime both to withdraw funds in this account and deposit as shareholdings, in whole or in part, as though no beneficiary had been named, and to change this contract by designation of other or additional beneficiaries. The interest of any beneficiary or beneficiaries shall not be interpreted to vest until my/our death. I/we further agree that no designation of beneficiary shall be valid unless executed in the form and manner acceptable to VACU at the time of the change and delivered to the credit union prior to my/our death. Any accounts held as joint tenants with right of survivorship, and not as tenants in common, must be signed by all owners to make a new beneficiary designation.

On my/our death the shareholder account, or any part thereof or any interest thereon shall be paid by the credit union to the Secretary of Social and Rehabilitation Services for a claim pursuant to K.S.A. 39-709(g) and amendments thereto, or if there is no such claim or if any portion of the account remains after such claim is satisfied, the designated beneficiary or beneficiaries. The receipt of the person so paid shall release and discharge the Credit Union for any such payment.

I/we agree that the credit union may properly refer to this contract as payable on death or POD.

If more than one person signs this contract and we are owners of an account or other moneys described herein as joint tenants with right of survivorship and not as tenants in common, then this contract is not meant to destroy such relationship, but to apply after death of the last of the said joint owners.

6.Authorization

By signing below, I/we agree to the terms and conditions as set forth in the “Terms and Conditions of Your Account,” a copy of which I/we further acknowledge receiving. I/we further acknowledge receiving the Rate and Fee Schedule, Electronic Funds Transfer, Funds Availability, and Truth in Savings disclosures incorporated with the “Terms and Condition of Your Account” documentation. In considering this application and/or any request for financial services, you authorize the Credit Union to check your credit and employment history, to request and use reports regarding same, and to answer questions about it’s credit experience with you.

_______________________________________
Signature

As soon as we receive your application, a VA Credit Union employee will contact you to verify information and let you know the status of your application. If you have any questions, please feel free to contact us at 316-651-3634.