ACCOUNT CHANGE REQUEST FORM CURRENT ACCOUNT INFORMATIONPrimary 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: OtherOther change type...Do you require more space for additional information?YesNoAdditional information:ADD OR REMOVE ACCOUNTS / SERVICESCheck the services you'd like to add or remove:* Payroll Deduction AddRemoveShare / Savings Share / Savings AddRemoveShare Draft / Checking Share Draft / Checking AddRemoveATM / Check Card ATM / Check Card AddRemoveStudent Checking Student Checking AddRemoveOver-Draft Protection Over-Draft Protection AddRemoveBounce Safe / Courtesy Pay Bounce Safe / Courtesy Pay AddRemoveHome Banking Home Banking AddRemoveFresh Start Checking Fresh Start Checking AddRemoveClub Account Club Account AddRemoveTouchtone Teller Touchtone Teller AddRemoveShare Certificate Share Certificate AddRemoveLine of Credit Line of Credit AddRemoveDirect Deposit Direct Deposit AddRemoveMoney Market Money Market AddRemoveBill Pay Bill Pay AddRemoveOther Other Other account or service...Do you require more space for additional information?YesNoAdditional information:NAME CHANGENew name: First Middle Last Driver's license number:ADDRESS / CONTACT INFO / EMPLOYER CHANGEWhich 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?YesNoNew 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?YesNoOccupation:New employer name:New employer address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code New employer phone number:Business phoneExt. New security / verification code, or mother's maiden name:CHANGE MAIL HANDLINGHold all mailRemove mail holdEffective date: ACCOUNT OWNERSHIP CHANGESPlease select which of the following actions you wish to take:Name/change account ownerName/change agentAdd 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 ACCOUNTSCheck all that apply: Share (savings) Club Certificate (CDs) Student CHECKING ACCOUNTSCheck all that apply: Free checking Fresh Start Student Money market OWNER INFORMATIONName: First Last Date of birth:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Social 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 phoneExt. Occupation:Driver's license state of issue:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDriver's license number: Grant Rights of Survivorship? Would you like to make another ownership change?YesNoName: First Last Date of birth:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Social 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 phoneExt. Occupation:Driver's license state of issue:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDriver'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. PRIMARYWill you be adding or removing a Beneficiary?AddRemoveACCOUNT 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:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone number:Add or remove another Beneficiary?YesNoWill you be adding or removing this Beneficiary?AddRemoveACCOUNT 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:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone number:Would you like to name or edit a Contingent Beneficiary?YesNoCONTINGENTWill you be adding or removing a Beneficiary?AddRemoveACCOUNT 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:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone number:Add or remove another Contingent?YesNoWill you be adding or removing this Beneficiary?AddRemoveACCOUNT 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:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone number:AUTHORIZATIONBy 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?YesNoSignatureDate: Type: Primary Joint Owner Agent Is another signature required? (2)YesNoSignatureDate: Type: Primary Joint Owner Agent Is another signature required? (3)YesNoSignatureDate: 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. NameThis field is for validation purposes and should be left unchanged.
