Ownership:
Member # (To be provided by the Credit Union)
Expiration Date Date of Birth Gender
State Zip
State Zip
State Zip
Membership Eligibility Requirements - Primary Member Only:
* If eligible through The Center for Community Self-Help: The Center for Community Self-Help is a 501(c)(3) nonprofit corporation dedicated to creating and protecting ownership and economic opportunity for people of color, women, rural residents, and low-wealth families and communities. Membership in the Center for Community Self-Help requires a $5 fee, which is a tax-deductible contribution.
Additional Information - Primary Member Only:
Providing this additional information is optional. We ask for it because it helps us better understand who our Members are and how we can better serve them. It also helps us when writing proposals to try and raise money for the Credit Union and when reporting on the same. The Credit Union does not discriminate on the basis of race, religion, national heritage ethnic background, gender or sexual preference.
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I prefer not to answer this information with the Credit Union.
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Native Hawaiian/Other Pacific IslanderƑ
WhiteƑ
Other (Please Indicate) ____________________ Are you Hispanic/Latino?Ƒ
YesƑ
NoHow many family members are in your household? ____________
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DissatisfactionƑ
SRI SearchƑ
SH BorrowerƑ
SH Loan BorrowerƑ
Ad/Mailer ____________________Ƒ
Article/Publication ____________________ (Please list) (Please list)Ƒ
Business or Professional Referral ____________________Ƒ
Event/Conference ____________________Ƒ
Internet Rate Search ___________________ (Please list) (Please list) (Please list)Ƒ
Other: ____________________ (Please list)Branch: Name of MSR:
FOR OFFICE USE ONLY
Employer Occupation
Eligibility Type: ______________________________ Group: ______________________________
What is your primary racial background?
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American Indian/Alaska NativeƑ
AsianƑ
Black/African AmericanWhat is your approximate household income? ________________
Other City
Referral Information - How did you hear about the Credit Union?
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Friend, Family or Co-WorkerMember Signature Date
Home Phone Cell Phone Work Phone E-Mail Address
Second Name Line Mother's Maiden Name
ID Type Number/Value Issued By
Physical Address City
Mailing Address City
Member Name Social Security Number
Personal Membership Application
Self-Help Credit Union, including its divisions may be referred to as "Credit Union."
Important Information About Procedures for Opening a New Account
To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account. What this means to you: When you open an account, we will ask for your name, address, date of birth or other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.
Member #: __________________
SSN #: ____________________
Account Type: __________________________________________________________
Suffix #: ____________________
Joint Owner Information
Middle Initial Suffix
Expiration Date Date of Birth Gender
State Zip
State Zip
Joint Owner Information
Middle Initial Suffix
Expiration Date Date of Birth Gender
State Zip
State Zip
are incorporated therein. I/we acknowledge receipt of the abovementioned disclosures, and any agreements and disclosures applicable to the accounts and services requested herein. Additionally, I/we specifically consent and agree that the Credit Union may provide the abovementioned legally required disclosures electronically on the Credit Union website, or in writing, or both.
I/we understand that in order to become, and remain, an active member of the Credit Union, a minimum of $5 must be maintained on account with the Credit Union. Yes, I/we want to open my/our Credit Union account(s) and join the Credit Union if my/our membership has not already been established. I/we hereby authorize the Credit Union to open the account(s). Furthermore, I/we affirm our commitment to the mission of the Center for Community Self-Help and acknowledge that I/we are making a $5 membership contribution to CCSH (if applicable).
Primary Member Signature Date
Joint Owner Signature Date
Joint Owner Signature Date
Employer Work Phone Occupation
Right of Survivorship: We understand that by establishing a joint account with right of survivorship under the provisions of N.C. Gen. Statute 54-109.58 that: (1) The Credit Union may pay the money in the account to, or on the order of, any person named in the account unless we have agreed with the Credit Union that withdrawals require more than one signature; and (2) Upon the death of one joint owner the money remaining in the account will belong to the surviving joint owners and will not pass to the heirs of the deceased joint owner or be controlled by the deceased joint owner's will. We DO elect to create the right of survivorship in this account
Agreement and Authorization Signatures
Substitute W-9 - TIN Certification
I certify in accordance with IRS W-9 instructions and under penalties of perjury, that: 1. The number shown on this form is my correct taxpayer identification number, 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.
3. I am a U.S. person (including a US resident alien). [Cross out item 3 if you are not a U.S. person, and initial here: ________]
*Joint account with Right of Survivorship - Definition
Physical Address City
Mailing Address City
Mother's Maiden Name Home Phone Cell Phone E-Mail Address
First Name Last Name Social Security Number
ID Type Number/Value Issued By
First Name Last Name Social Security Number
New Account Selection
Primary Member Name: ___________________________________________________
Ownership Type:
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Individual
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Joint with Right of Survivorship*
By signing below, I/we agree to the terms and conditions of the Membership and Account Agreement, Truth-in-Savings Disclosures, Funds Availability Policy, Electronic Fund Transfers Agreement and Disclosure, Privacy Notice Disclosure and Rate and Fee Schedules; and to any amendment the Credit Union makes from time to time which
Mailing Address City
ID Type Number/Value Issued By
Physical Address City
Mother's Maiden Name Home Phone Cell Phone E-Mail Address
Personal Membership Application
Help Sheet
Thank you for your interest in membership with Self Help Credit Union. Please read the following information to assist you in completing the necessary information for membership. If any part of the required information is not received, your membership will be delayed until such time as all necessary items are received. If you have any questions as you complete this form, please contact your local branch for assistance.
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Ownership
Indicate the type of account to establish: Personal, Custodial, Estate, Minor, Minor – UTMA. All accounts established require additional forms based on the type of account opened.
Member Number
This will be assigned by the Credit Union.
Primary Member Information
Complete the Primary Member information section completing all information. If a section does not apply to you, please indicate by N/A.
• Member Name – Enter your name as the account should be titled
• Social Security Number – Enter your full social security number or ITIN
• Second Name Line - Leave Blank
• Mother’s Maiden Name – Enter your Mother’s Maiden Name
• ID Type – Enter ID type for verification. Acceptable types include: Driver’s License, Passport, State Issued ID or
Military ID
• Number/Value – Enter ID number for ID type
• Issued By – Enter Issuing State or Agency
• Expiration Date – Enter expiration date of ID Type
• Date of Birth – Enter Date of Birth – date will format to mm/dd/yyyy
• Gender – Enter Gender
• Physical Address – Enter you full physical address including city, state and zip
• Mailing Address – Enter a mailing address if different from physical address
• Other Address – Leave Blank
• Home Phone – Enter Home phone number (Note: If you have a cell phone as your home phone list here also)
• Cell Phone – Enter your Cell phone number
• Work Phone – Enter your Work phone number
• E-mail Address – Enter your primary E-mail address
• Employer – Enter your current Employer (Note: If Retired please list last Employer)
• Occupation – Enter your current Occupation (Note: If Retired please list last Occupation)
Member Eligibility Requirements Designation
Follow the guidelines below to determine the appropriate membership eligibility designation for you.
Eligibility Type
Choose Eligibility Type from list as: Geographic, Employer/Association or Family. See below for definition of each.
Geographic
The Durham office does not fall into this category. Self Help offices are located in the following counties: Brunswick,
Group
Choose Group from list as: Live, Work, Worship or Attend School in any of the counties listed above.
Select Employee Group/Association
If you reside in a state other than North Carolina, or if you plan to submit your application to our Durham office, please choose Select Employee Group/Association, and follow the instructions for joining through the Center for Community Self-Help.
Family Member
An immediate family member is defined as a spouse, parent, sibling, or child.
Additional Information
New Account Selection
Help Sheet
Thank you for your interest in membership with Self Help Credit Union. Please read the following information to assist you in completing the necessary information for membership. If any part of the required information is not received, your membership will be delayed until such time as all necessary items are received. If you have any questions as you complete this form, please contact your local branch for assistance.
___________________________________________________________________________________
Member Number
This will be assigned by the Credit Union.
Account Type
Full account descriptions are available on our Website www.self-help.org, any Credit Union branch or the Durham office. Indicate the type of account being opened. Please note that a form needs to be completed for each type of account (i.e. Savings, Checking, Money Market, etc.) The suffix will be system assigned and will be entered by a Credit Union employee.
Ownership
Indicate the ownership for the account. The following describes the types of ownership:
Individual Account (without a named Payable on Death Beneficiary) is an Account which is owned by one
individual. The owner of the account has full transaction authority. Upon the death of such individual, the remaining funds belong to the individual’s estate.
Joint Account with Right of Survivorship is an Account which is owned by two or more individuals. Each joint
owner has full transaction authority and ownership of account funds. Upon the death of one of the joint owners, the remaining funds belong equally to all surviving joint owner(s).
Joint Owner Information
Complete the Joint Owner information for all joint owners on the account, making sure to complete all information. If a section does not apply, please indicate by N/A.
• First Name, Middle Initial, Last Name & Suffix – Enter your name as the joint owner
• Social Security Number – Enter your full social security number or ITIN
• ID Type – Enter ID type for verification. Acceptable types include: Driver’s License, Passport, State Issued ID or
Military ID
• Number/Value – Enter ID number for ID type
• Issued By – Enter Issuing State or Agency
• Expiration Date – Enter expiration date of ID Type
• Date of Birth – Enter Date of Birth – date will format to mm/dd/yyyy
• Gender – Enter Gender
• Physical Address – Enter you full physical address including city, state and zip
• Mailing Address – Enter a mailing address if different from physical address
• Mother’s Maiden Name – Enter your Mother’s Maiden Name
• Home Phone – Enter Home phone number (Note: If you have a cell phone as your home phone list here also)
• Cell Phone – Enter your Cell phone number
• E-mail Address – Enter your primary E-mail address
• Employer – Enter your current Employer (Note: If Retired please list last Employer)
• Work Phone – Enter your Work phone number
Additional Credit Union Products & Services
Health Savings Account (HSA)
The Credit Union offers HSA checking accounts. An HSA is an account designed for use with a High-Deductible Health Plan. If eligible, additional paperwork is required to open this account. The Credit Union also offers a debit card for these accounts.
Online Banking
Get access to your Credit Union account information, as well as e-statements (free) and Bill Pay (read the Bill Pay description for information on how to avoid the monthly fee for this service). Access this service via our website https://www.self-help.org/. The Credit Union will provide you with your online banking username and temporary password.
Bill Pay
Access this service at no charge when you have any two of the following three Credit Union services: direct deposit, e-statements, and the Self-Help Credit Union debit card. Otherwise, a monthly service fee is charged (see the Credit Union fee schedule for details).
E-Statements
Replace paper statements with statements that you view online. Connect to E-statements free of charge using our online banking service.
Debit and ATM Cards
Self-Help Credit Union offers free Debit and ATM cards. The cards can be used nationwide with surcharge-free access to your Credit Union funds at ATM terminals that display the CO-OP network logo. A Credit Union checking account is required with the debit card.
Audio Banking
Request your individualized username and password from the Credit Union after establishing membership, and access your Credit Union account information by calling 1-866-708-0694 toll-free.
Overdraft Coverage
Overdraft Transfer: The source account for overdraft transfer must be a Credit Union savings or checking account (term certificates not included). A fee is charged for each transfer (see the Credit Union fee schedule for fee details).
Overdraft Line of Credit: Use this loan product to cover shortages in your Credit Union checking account and to avoid NSF fees. Applicants for an overdraft line of credit must meet the loan approval guidelines of the Credit Union. The overdraft line of credit carries an interest rate (see the Credit Union fee schedule for details).
Direct Deposit
Contact your employer about depositing your paychecks into your Credit Union savings or checking accounts. Also, if you receive payments from the federal government, then look into the U.S. Treasury Department’s Go Direct program for direct deposit of those funds into your Credit Union deposit accounts.
Personalized Printed Checks
Checks can be ordered at the time you open your checking account or money market account, or you can order checks on your own at any time after opening the account. To order checks you will need our routing number and your Credit Union checking account number. The check ordering fee will be taken out of your checking account.
Credit Cards
Substitute W-9 - TIN Certification
Read this section thoroughly. Sign and date as required. Account disclosures are available on our website and at the Credit Union.
