Trusted Contact Form

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

How to add a Trusted Contact

Speak with a Star One Representative at any Star One branch, or online with our Virtual Branch
- Find a local branch and make an appointment
Or, by mail
- Fill out this form, have it notarized, and mail it to: Star One Credit Union, P.O. Box 3643, Sunnyvale, CA 94088

Designate your Trusted Contacts

I hereby authorize Star One Credit Union to contact the individual(s) identified below as my Trusted Contact(s) at the Credit Union’s discretion, if concern(s) arise regarding my membership(s) to:

Address suspicious financial activity
Confirm the specifics of my current contact information
Inquire about my current health status
Confirm the name of my legal guardian, executor, trustee, or holder of the power of attorney

Member name

Member number *

* This authorization will apply to all memberships where the individual is an authorized signer.

Primary Trusted Contact

Name

Phone

Date of birth (optional)

Relationship

Address

Secondary Trusted Contact (optional)

Name

Phone

Date of birth (optional)

Relationship

Address

By signing this document, I authorize Star One Credit Union to contact my Trusted Contact(s) at their discretion. I understand that my authorization is optional. I understand I may withdraw my authorization or change my Trusted Contact at any time by notifying the Credit Union in writing. I certify that the individual(s) listed above are 18 years of age or older. I acknowledge that the Trusted Contact Authorization Form does not give any person authorization to act on my behalf or to execute transactions, or engage in activity in my account other than to receive information. My Trusted Contact will only be contacted for the reasons listed above.

I further agree that (1) Star One Credit Union is authorized to provide any information regarding me or my account(s) to a Trusted Contact, including but not limited to non-public personal information; (2) Star One Credit Union is not required to monitor my account(s) or contact or attempt to contact my Trusted Contact(s); and (3) I will indemnify, defend, and hold harmless Star One Credit Union from all claims, courses of action, damages, losses, expenses, costs, and liabilities of any kind that may arise out of, relate to or are in connection with the release of personal and/or account information to the Trusted Contact(s).

If updates are being made, this will supersede the current Trusted Contact Authorization form on file.

___________________________________________
Signature

______________________
Date

NOTE: A NOTARY ACKNOWLEDGMENT WILL BE REQUIRED IF IT IS NOT SIGNED IN THE PRESENCE OF A STAR ONE REPRESENTATIVE.

Revocation

I revoke the authorization above

___________________________________________
Signature

______________________
Date

Star One Credit Union use only

Authorization accepted by

Date

Revocation accepted by

Date

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