Account Change Request Form

CURRENT ACCOUNT INFORMATION

Primary member's full name:*

First Middle Last

Please list the account numbers that need changing:*

CHANGE TYPE(S)

Check all that apply:*

Add / Close Account
Add / Remove Owner
Address / Phone / Email Change
Name Change
Beneficiary Change (excludes trust accounts)
Add / Remove Service(s)
Mail Handling Change
Other:

Other

Other change type...

Do you require more space for additional information?

Yes
No

Additional information:

ADD OR REMOVE ACCOUNTS / SERVICES

Check the services you'd like to add or remove:*

Payroll Deduction

Add
Remove

Share / Savings

Share / Savings

Add
Remove

Share Draft / Checking

Share Draft / Checking

Add
Remove

ATM / Check Card

ATM / Check Card

Add
Remove

Student Checking

Student Checking

Add
Remove

Over-Draft Protection

Over-Draft Protection

Add
Remove

Bounce Safe / Courtesy Pay

Bounce Safe / Courtesy Pay

Add
Remove

Home Banking

Home Banking

Add
Remove

Fresh Start Checking

Fresh Start Checking

Add
Remove

Club Account

Club Account

Add
Remove

Touchtone Teller

Touchtone Teller

Add
Remove

Share Certificate

Share Certificate

Add
Remove

Line of Credit

Line of Credit

Add
Remove

Direct Deposit

Direct Deposit

Add
Remove

Money Market

Money Market

Add
Remove

Bill Pay

Bill Pay

Add
Remove

Other

Other

Other account or service...

Do you require more space for additional information?

Yes
No

Additional information:

NAME CHANGE

New name:

First Middle Last

Driver's license number:

ADDRESS / CONTACT INFO / EMPLOYER CHANGE

Which of the following are you looking to change?

Address(es)
Phone number(s)
Email
Employer information

New physical address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Is the new mailing address the same as the above?

Yes
No

New mailing address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home phone:

Cell phone:

New email address:

Enter Email Confirm Email

Have you retired from this occupation?

Yes
No

Occupation:

New employer name:

New employer address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

New employer phone number:

Business phone	Ext.

New security / verification code, or mother's maiden name:

CHANGE MAIL HANDLING

Hold all mail
Remove mail hold

Effective date:

ACCOUNT OWNERSHIP CHANGES

Please select which of the following actions you wish to take:

Name/change account owner
Name/change agent
Add owner
*Remove owner

I/we agree.

*By choosing the “Remove Owner” option above, you have chosen to remove the selected owner(s) from the account(s) designated on this form. You understand that removal of a Multiple Party Account Owner requires consent of all account owners, and you will hold the credit union harmless for actions regarding account access. The removed account owner(s) relinquishes ownership interest including any membership share in the account(s) set forth above. This relinquishment does not affect your obligation of any loan account(s).

SHARE / SAVINGS ACCOUNTS

Check all that apply:

Share (savings)
Club
Certificate (CDs)
Student

CHECKING ACCOUNTS

Check all that apply:

Free checking
Fresh Start
Student
Money market

OWNER INFORMATION

Name:

First Last

Date of birth:

Social Security Number:

Physical address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Mailing address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home phone:

Cell phone:

Email:

Enter Email Confirm Email

Employer:

New employer phone number:

Business phone	Ext.

Occupation:

Driver's license state of issue:

Driver's license number:

Grant Rights of Survivorship?

Would you like to make another ownership change?

Yes
No

Name:

First Last

Date of birth:

Social Security Number:

Physical address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Mailing address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home phone:

Cell phone:

Email:

Enter Email Confirm Email

Employer:

New employer phone number:

Business phone	Ext.

Occupation:

Driver's license state of issue:

Driver's license number:

Grant Rights of Survivorship?

PAYABLE ON DEATH BENEFICIARIES

By signing below, each party designates the person(s) named below as Payable on Death Beneficiaries on the accounts indicated. You agree to save, defend and hold The Focus Federal Credit Union harmless from any liability in connection with this POD designation. Designation not available on Multiple Party Accounts without Right of Survivorship.

I agree.

PRIMARY

Will you be adding or removing a Beneficiary?

Add
Remove

ACCOUNT TYPE(S):

SHARE / SAVINGS ACCOUNTS

Share (savings)
Club
Certificate (CDs)
Student

CHECKING ACCOUNTS

Free checking
Fresh Start
Student
Money market

Name:

First Middle Last

Social Security Number:

Relationship:

Physical address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date of birth:

Phone number:

Add or remove another Beneficiary?

Yes
No

Will you be adding or removing this Beneficiary?

Add
Remove

ACCOUNT TYPE(S):

SHARE / SAVINGS ACCOUNTS

Share (savings)
Club
Certificate (CDs)
Student

CHECKING ACCOUNTS

Free checking
Fresh Start
Student
Money market

Name:

First Middle Last

Social Security Number:

Relationship:

Physical address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date of birth:

Phone number:

Would you like to name or edit a Contingent Beneficiary?

Yes
No

CONTINGENT

Will you be adding or removing a Beneficiary?

Add
Remove

ACCOUNT TYPE(S):

SHARE / SAVINGS ACCOUNTS

Share (savings)
Club
Certificate (CDs)
Student

CHECKING ACCOUNTS

Free checking
Fresh Start
Student
Money market

Name:

First Middle Last

Social Security Number:

Relationship:

Physical address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date of birth:

Phone number:

Add or remove another Contingent?

Yes
No

Will you be adding or removing this Beneficiary?

Add
Remove

ACCOUNT TYPE(S):

SHARE / SAVINGS ACCOUNTS

Share (savings)
Club
Certificate (CDs)
Student

CHECKING ACCOUNTS

Free checking
Fresh Start
Student
Money market

Name:

First Middle Last

Social Security Number:

Relationship:

Physical address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date of birth:

Phone number:

AUTHORIZATION

By signing below, I/we agree that the changes on this form amend the previously signed Membership Document and are subject to the terms and conditions of the Membership Disclosure, Schedule of Fees and Charges, and to any amendment the credit union makes from time to time which are incorporated herein.

*

Check this box to sign the form.

Signature*

Date:*

Type:*

Primary
Joint Owner
Agent

Is another signature required?

Yes
No

Signature

Date:

Type:

Primary
Joint Owner
Agent

Is another signature required? (2)

Yes
No

Signature

Date:

Type:

Primary
Joint Owner
Agent

Is another signature required? (3)

Yes
No

Signature

Date:

Type:

Primary
Joint Owner
Agent

I/We, the above members of The Focus Federal Credit Union have elected to opt out of my personal information being shared with FFCU business partners.

Name

This field is for validation purposes and should be left unchanged.

CURRENT ACCOUNT INFORMATION

CHANGE TYPE(S)

ADD OR REMOVE ACCOUNTS / SERVICES

NAME CHANGE

ADDRESS / CONTACT INFO / EMPLOYER CHANGE

CHANGE MAIL HANDLING

ACCOUNT OWNERSHIP CHANGES

SHARE / SAVINGS ACCOUNTS

CHECKING ACCOUNTS

OWNER INFORMATION

PAYABLE ON DEATH BENEFICIARIES

PRIMARY

ACCOUNT TYPE(S):

SHARE / SAVINGS ACCOUNTS

CHECKING ACCOUNTS

ACCOUNT TYPE(S):

SHARE / SAVINGS ACCOUNTS

CHECKING ACCOUNTS

CONTINGENT

ACCOUNT TYPE(S):

SHARE / SAVINGS ACCOUNTS

CHECKING ACCOUNTS

ACCOUNT TYPE(S):

SHARE / SAVINGS ACCOUNTS

CHECKING ACCOUNTS

AUTHORIZATION

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