Membership Application and Account Card - Representative Payee

This form requires a notarized signature.

Want to skip the notary requirement?

To skip, please choose one of these options:

Make a Virtual Branch video appointment, or
Visit a Star One Branch

Instructions

Read and accept the two disclosures provided
Fully complete the form
Print the form
Sign the form in front of a notary
Gather supporting document for Representative Payee membership:
- Social Security Administration Benefit Letter
Photocopy your valid U.S. driver's license or State-issued ID card
Mail the photocopy, supporting document, and printed form to Star One Credit Union, P.O. Box 3643, Sunnyvale CA 94088-3643

To avoid processing delays, and to collect your most current information, the Member Application and Account Card must be completed in its entirety.

NCUA

Your savings federally insured to at least $250,000 and backed by the full faith and credit of the United States Government. National Credit Union Administration, a U.S. Government Agency.

Representative Payee

Additional supporting document required for Representative Payee membership:

Social Security Administration Benefit Letter

Please include this document when you mail in this printed form.

Pay-on-Death Beneficiaries

Upon the death of the recipient, the remaining funds are transferred to the recipient's estate. No other beneficiary can be assigned.

TIN Certification and Backup Withholding Information

By signing this document, I certify, under penalties of perjury, that (1) I am a U.S. person (including a U.S. resident alien), (2) the Social Security Number (SSN)/taxpayer identification number (TIN) shown is my/the correct identification number and (3) I am NOT, unless designated below, subject to backup withholding because I have not been notified that I am subject to backup withholding as a result of a failure to report all dividends or interest, or because the IRS has notified me that I am no longer subject to backup withholding. Check below applicable boxes:

I am subject to backup withholding I am exempt from backup witholding I am NOT a United States citizen or U.S. person (complete W-8BEN form)

Acknowledgements

Consent to Utilize Credit Report for Additional Services:

Occasionally, Star One Credit Union uses information obtained from an applicant's credit report to evaluate if additional products or services will enhance the financial well-being of the applicant. To enable Star One to provide this valuable service, we have added this disclosure to request your authorization to used information in your credit report to make future credit offers.

I authorize Star One Credit Union to use my credit report for additional loan approvals and in consideration whether to offer other services to me.

For Account and/or Account Service Requests: by signing below, you acknowledge that you have received and agree to the terms and conditions contained in the Membership and Account Agreement, Truth in Savings Disclosure, Funds Availability Policy Disclosure, Electronic Funds Transfer Agreement and Disclosure and Privacy Notice and to any amendments to these documents that the Credit Union may make from time to time.

The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

This Membership Application and Account Card must be signed by all account owners. If updates are being made, this will supersede the current Membership Application and Account Card on file.

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Representative Payee

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Date

Note: Valid ID must be provided to a Star One Credit Union representative. Notary Acknowledgement required when not executed in branch in the presence of a Star One Credit Union representative.

Star One Credit Union use only

Operator ID & Initials

Date

Rev: 5/26/2021

Don't forget to include the supporting document required for Representative Payee membership when you mail in this form: