TALERIS CREDIT UNION, INC. FIDUCIARY (CUSTODIAL) MEMBERSHIP APPLICATION 
1.	Qualification for Membership | WE CANNOT PROCESS YOUR APPLICATION WITHOUT THE REQUIRED PROOF OF ELIGIBILITY
TO BE ELIGIBLE FOR MEMBERSHIP, YOU MUST LIVE, WORK, ATTEND SCHOOL OR WORSHIP IN CUYAHOGA, MEDINA, LORAIN, LAKE, SUMMIT, GEAUGA, PORTAGE, ASHTABULA, ASHLAND, WAYNE, COLUMBIANA, MAHONING, TRUMBULL, OR STARK COUNTY OR, WORK FOR A TALERIS CORPORATE PARTNER, OR BE A RELATIVE OF A CURRENT TALERIS MEMBER, OR JOIN A PARTICIPATING ASSOCIATION.
A complete listing of Taleris Corporate Partners and participating associations can be found at www.taleriscu.org/partners+associations/
VALID IDENTIFICATION INCLUDES: a valid Ohio Driver’s license or State ID. If you are eligible because of where you work, attend school or worship, include a recent pay stub, or a school schedule, or a donation envelope or letter from your place of worship. Family Referral Letters are available at www.taleriscu.org/ applications or call 800.828.6446. Association membership requires an additional, one time $5.00 fee added to your initial deposit.

CHECK ONLY ONE:	New Application	Update  		 		
		Membership Number	Date	

Live

Work

Attend School

Worship

Cuyahoga	Medina	Lorain	Lake	Summit	Geauga	Portage	Stark
Ashtabula	Ashland	Trumbull	Wayne	Mahoning	Columbiana

Work for Taleris Corporate Partner (Enter company name. Include recent pay stub)
Relative of current Taleris Member (Enter Member Name. Include Family Referral Letter)
Join Association (requires additional $5 added to initial deposit)	Public Animal Welfare Society	Seven Hills Historical Society

CHECK ONE	IF YOU CHECKED LIVE, WORK, ATTEND SCHOOL, OR WORSHIP—CHECK TO INDICATE YOUR COUNTY

2.	Enclose Initial Deposit to open account (Association Members require an additional $5.00 in initial deposit to cover Association Fee)
AN INITIAL DEPOSIT MUST BE INCLUDED WITH THIS APPLICATION. Minimum deposit is $5.00 — check or money order Payable to: Taleris CU is preferred.
DO NOT SEND CASH. NOTE: If you are eligible because of Association Membership, include the $5 Assoc. Fee with your initial deposit (can be totaled on one check).

Initial Deposit Amount 		Check	Money Order	Other  	

3.	Custodial account type (For descriptions, see the Account Ownership Types form available at www.taleriscu.org/applications or call 800.828.6446.
Custodian (Minor)	Guardian (Ward)	Representative Payee (Recipient of SS funds)	Estate (Executor/Executrix)

4.	Enter your Personal Information

MINOR, WARD, RECIPIENT, ESTATE INFORMATION
 	FILL OUT COMPLETELY	

CUSTODIAN, GUARDIAN, REPRESENTATIVE PAYEE, EXECUTOR/
 	EXECUTRIX INFORMATION - FILL OUT COMPLETELY	

First Name

Initial

Last Name

First Name

Initial

Last Name

Street Address

Apt.#

Street Address

Apt.#

PO Box

City

PO Box

City

State

Zip

Home Phone

State

Zip

Home Phone

Work Phone (and area code)

Cell Phone (and area code)

Work Phone (and area code)

Cell Phone (and area code)

SSN/TIN#

Mother’s Maiden Name

SSN/TIN#

Mother’s Maiden Name

ID# (Driver’s License or Approved ID)

State of Issue	Exp. Date (mm/dd/yyyy)

ID# (Driver’s License or Approved ID)

State of Issue	Exp. Date (mm/dd/yyyy)

Date of Birth (mm/dd/yyyy)

Own Home? Yes/ No

Date of Birth (mm/dd/yyyy)

Own Home? Yes/ No

Current Employer

Occupation

Current Employer

Occupation

E-mail Address

E-mail Address

BEST WAY TO REACH ME DURING NORMAL BUSINESS HOURS:

BEST WAY TO REACH ME DURING NORMAL BUSINESS HOURS:

Home Phone

Work Phone

Cell Phone

Email

Home Phone

Work Phone

Cell Phone

Email

continued on next side

SUCCESSOR CUSTODIAN INFORMATION - FILL OUT ONLY TO DESIGNATE A SUCCESSOR CUSTODIAN
The Successor Custodian has no authority over the account until the Custodian is deceased or legally declared incompetent

First Name	Initial	Last Name

Street Address	Apt.# / PO Box	City	State	Zip

Home Phone (and area code)	Work Phone (and area code)	Cell Phone (and area code) Email Address
5.	
No ATM/Debit Card

Account Options:
No Checks
with my checking account

Choose accounts
Primary Savings (required for membership)

Classic Checking (Interest Bearing)	Basic Checking (No Monthly Fee)
I am also interested in learning more about:

Auto Loans	Home Equity Loans	Mortgage Loans	Personal Loans	Bill Consolidation Loans	
Money Market	IRA’s	Holiday Savings Acct.	Online Bill Pay	Term Share Certificate	

6.	Declaration For the Primary member Check appropriate statement(s) in this section, sign and date.
I AM A U. S. PERSON Includes U.S. Citizen, U.S. Resident Alien, Partnership Corporation, company or corporation created or organized in the United States or under the laws of the United States, an estate (other than a foreign estate) or a domestic trust.
Under penalty of perjury, I certify: (1) The number shown on this form is my correct taxpayer ID number (or I am waiting for a number to be issued to me), 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 failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and (3) I am a U.S. person (including a U.S. resident alien).
I am NOT a U.S. Person.	(Complete IRS Form W8BEN) I am subject to backup withholding.
The Internal Revenue service does not require your consent to any provisions of this document other than the certifications required to avoid backup withholding.
Signature of Custodian, Guardian, Representative Payee, Executor/Executrix	Date

7.	Sign application
I hereby make application for membership in Taleris Credit Union (TCU) and agree to conform to its articles, bylaws and regulations, and to subscribe for at least one (1) share. I agree to be bound by the applicable agreements which have been provided to me in current form for the accounts and services listed herein.

Note: All accounts are insured to $250,000 by ASI (American Share Insurance), a private member owned insurer. This institution is not federally insured, and if the institution fails, the Federal Government does not guarantee that depositors will get back their money. MEMBERS’ ACCOUNTS ARE NOT INSURED OR GUARANTEED BY ANY GOVERNMENT OR GOVERNMENT SPONSORED AGENCY.
By signing below, I certify that the information on this application is complete, true and submitted for the purpose of obtaining the accounts and services requested. I agree that for the purpose of: (a) verifying information on this application or (b) extending credit or services to me or (c) reviewing or collecting my credit accounts, Taleris Credit Union may, at any time, utilize a credit reporting agency to obtain my credit report and/or verify my employment.
I understand that this application must be completed in its entirety for Taleris to process my request.

Signature of Custodian, Guardian, Representative Payee, Executor/Executrix	Date

8.	How Did You Hear About Us?
Work For  	

Family or Friend	Previous Member	Branch Banner

Radio Ad	Print Ad	TV Ad	Online	Other (please specify below)

FOR OFFICE USE ONLY: SEG #   	

Mail To: Taleris Credit Union, Inc. | ATTENTION: Member Services 
P.O. BOX 318072
Cleveland, OH  44131-8072

R

YOUR SAVINGS INSURED TO $250,000 PER ACCOUNT. This institution is not federally insured, and if the institution fails, the Federal Government does not guarantee that depositors will get back theirmoney.

OPPORTUNITY

MEMBERS’ACCOUNTS ARE NOT INSURED OR GUARANTEED BY ANY GOVERNMENT OR GOVERNMENT-SPONSORED AGENCY.	EQUAL HOUSING

MD0.063	08/20/19