Membership
Application



Filed in Fourth Judicial Disirici Court

1116555 [9

l.I

 

AFFINITY PLUS

FEDERAL Chin" 

 

NAME DOROTHY CIBALENT

MEMBER NUMBER

 

ELIGIBILITY FOR MEMBERSHIP
Through employer. Sign LS. g. 111; {[ng g: i

Bybeing asiudenlalialumniol: Ch??h?lPVL?lr 1E. 
Cl Name ol relative:

Dues paying member of Allinily Plus Foundalion?.
?Pious: am Midi-y Pius Fuundnla?uo Mambo: nonpro?t: 57mm

Relationship:

PRIMARY MEMBER INFORMATION

Social Securily ll:_

 

Driver?s License II:

 

Birth date: e-mail:

 

Address:_

 

(my: newenroerou Slate: MM

Lived in analher slalo in the 10515 Yes. where?:

Zip; 55112

Home Phone:

 

 

Work Phone: exit
Employer:

 


Nearcsl relolive no! living wilh you:

 

Phone: Relation:

Jon? OWNER INFORMATION

Name:

 

 

 

Social Securily 
Driver's License fl:

 

dale:
Employer:

some as primary

 

 

~i?lilei'OImIJrualion:
For all accuunls Cl For only:

 

PAYABLE ON DEATH Bene?ciary Designelion

Name:

 

Address:

 

Birlh dale:

 

Social Securiiy ii:

BASIC SERVICES WANTED

El Membership Savings Amounl ($10 minimum balance)
13 Checking (choose one): Free Progressivre El Free?zBU?"
Pedigipalion Checking?: Boiler Than Free C1 lnlerest Reward
SIarIing Check ll:
Debit Card .

13 Free Overdrall Proleclion andlor line of credll?
"mac Is no annual I90 hr an ine 01min. Iniucsl chalgus will apply.

 

I would Illre more iniormallon on ihe Ioilowing

 

New CHECKING Accoum

Have you had a Iranseclion aocuunl at Ihis or enolhur ?nancial Insiiluiion wilhin the
last ?12 monlhs? {3 Yes N0 .
Have you had a Iransaclion encounl closed by a ?nancial instiluiiun willmuiyour consenl
In lhr: Iasl 12 munihs? 1:1 Yes 1:1 No

Have you been convlcied of a criminal oilense because 0! I110 use of a check or olher
similarilom with Iho I051 24 monihs? Yes No

Have you ?ver! in anniharsiaie within Ihe Iasi live years? [3 Yes N0

Taxpayer Certi?cation And Backup Withholding info

By si ning below, I warlil in ambulance with rm: IRS W-S insiruclions provided by In: men union 0an un?t
pundgos 01 poring, the] 0 Social SHUIHI Number Mambo: show I: myth:
conecl Idenlii'mlon number and MI I 40!. 011105: des?gnmd balm. whim Ia backup mirthuir?nn becausol
have noI been mliicn mu! I am :00qu lo back up minimising as a row? ul a 13901qu rayon ail dirldunds or Interest
or banana IN: as has noIBna-rnc mm am onion er simian IO backup withholding. and um I :01 man Unsignaiud
below. 0 no person [Including 0 U.S.rclidunl 01qu

1 Im 001 0 United Slain: 00m w-e 101m)

Ulomsuhjo: .u hholding
1011512013
1

1m Slannluro Dal:

 
 
  
 

By wbmi?n 0115 application. I ccnily on I war be receiving my 9011ch Maternal?; clownn'toiy through Mm: Plus
(mine I: no.1 undusland Hull 1.11 00 suppiod a use: aaruormni within Ilia Term: and 0i Iha acwunI
that com min [110 E-Siun MI I win continue In locum papa; slammunis unu I hm nucessluly logged lnIo
Amen lus Unlinn Earning. Upon con?rmation of ecceuibifl . I begin rocuiving my raglan-c siaiomcm:
memory Imaywimdnw mycomni Ior :Iccifonla :lnlemzrnu )1 :unlouEngAI?eiy aIunr Irma.

By signing hem. lundnruand I inn applying for membership In Af?nity Plus Fedora: Cru?l Union end am Insimciina
1hr: 01061100100 10 open In my now: [he mums checked ?0111me I110 lnlomaiiun provisions on this
agiecmm [a 1m 0an tome: and um um mm on I111: 3ng a! monk. I eerily 
Security Number I: med. I wil reach: and I uudasm 3131i: shoal and Ian
lulu-mean: 09100 to lira mics and punk: oi Molly Pins Federal Credil Union am! np?'tabln 1000001 Imus and
candr?lions as amended Irom Hum 10 [med 1101310111: Nani}; Plus Federal Cll?i'l Union in yciily um 3:10 
minor Ir; any necessary mam lrziuqing pigyam?w? of a credll rape! by autoimmune agency. 100::ch urc?on
solo! my and niliaiilikes (In iridium iuinll the annual ownu[s)mnv have the man unboil aI
all)I Em! {ha ucdli union. In (1006157131, believes the [he l?mbll?ilesls In I Iunru 0!
Ion! uhh?rhmy 0031000150 in Iheue?l onion?? Illa ieqwnd

dopuslls for any other annuals I or Ionpnn?lli 0pm uhuklnn account I one: 50111101115100: oi checks. in
visa. Dab/Ii Card and For as ml 05 a llama nus PM I undersized mar loans aw subicci to u:

approval.



Prim lagoon Signature

%/8f4 1011512013
Dale

1 011 5(2013
Mnmbor 5501131010 Gale

 

USA Pmlul MI

1: help Br. 5 gamma In; looting cl (mum and money 1311061253, ledera?. lemurs?: 0081211611 imraluimr
I: oh! 0 1; and record Womtm mama-16m each 011ml a! mum} elm-J1 as your name. address. ml dries?
muse. go new you A?n'ry Hus Emmi: Irma my one a terminal early, phase to mum w: he and In no:
11111213195qu More 

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lag orrlcergeeien} $119021: Ferrari - 10011403320391: 5: 13.1.1.4, A
{?beif-R??gzk- ?f 91531;.? 
?iraiinH?rEE?iziis??ylg'gc 129mm? 6? 
1111?" ?fm?a' 310011

9/18/2015 10:22:58 AM
Hennepin County, MN

 

 

 

 

 

10/21/2019



CONFIDENTIAL

 

 

 

AP00075