Mail
completed form to:
Mid American Credit Union
8404 West Kellogg Drive
Wichita, Kansas 67209
MID AMERICAN CREDIT UNION ID VERIFICATION FORM
Instructions: Complete all the information on this form and
sign the form at the bottom. Your signature will need to
be notarized prior to you returning this form to the credit union. Once we have
the completed form, your account
will be updated with the information. If you have anyquestions
about how to complete this form, please call Financial
Services at 316-722-3921, ext. 202.
Date______________ Account Number__________________________
Member Name_____________________________________________
Member Street Address_______________________________________
City________________________ State__________ Zip___________
_______________________________________________________
Member Mailing Address (if different from Street Address)
City________________________ State__________ Zip___________
Social Security Number ____________________Date of Birth__________
The Patriot Act requires that we maintain information from a
government issued photo ID. Pleaseindicate that type
of ID used by placing a "X" in the appropriate box and then give the
state or military branch of issue and the ID
number. If you do not have a government issued photo ID, pleasecontact Financial
Services at 316-722-3921, ext 202
for further instructions.
| TYPE OF ID USED | ORIGIN | NUMBER |
| Driver’s License | State: | Number: |
| Passport | Country: | Number: |
| State ID | State: | Number: |
| Military ID | Branch: | Number: |
| Other Means of Verification (specify) |
||
| FOR ID USED | Date of Issue: | Expiration Date: |
I certify that the information furnished above is correct. Signature:_______________________________
| Notary Signed and affirmed before me on the _____ day of _____________, 2____ . (seal) Signature of notary public________________________________________ |
|
Mail
completed form to: |
|