Financial ICCU Form

FINANCIAL ICCU FORM

1. Applicant / Account Identification

2. Requested Action

Please select the action you are requesting the institution to undertake on your behalf:

Open new account

Update account information

Close account

Wire / ACH authorization (domestic/international)

3. Entity Type & Tax Classification

Select the entity type that best describes the applicant. Selecting subsequent classifications constitutes a representation the applicant satisfies all legal criteria for such classification.

Individual

Sole proprietor

Corporation

Partnership

Trust / Estate

Government / Public Entity

Other:

4. Beneficial Ownership (Owners with 25%+ Interest)

Provide beneficial owners who directly or indirectly own 25% or more of the applicant, or indicate none if not applicable.

If additional beneficial owners exist, attach an addendum bearing the same certifications and signatures required by this form.

5. Authorized Signers and Operating Instructions

List individuals authorized to transact on the account. The institution will rely on these signatures for instructions until written notice of change is received.

6. Financial Profile

7. Legal Certifications & Authorizations

By signing below, the applicant certifies that the information provided in this Financial ICCU Form is true, complete, and accurate. Applicant authorizes the institution to verify any information provided, to obtain consumer or commercial credit reports where permitted by law, and to request supporting documentation as necessary. Applicant further authorizes the institution to act upon instructions received from authorized signers until written notice of change is delivered and acknowledged.

I authorize the institution to obtain credit and identity verification reports as required for account opening and ongoing due diligence.

I authorize the institution to execute wire and ACH transactions in accordance with submitted instructions and internal risk controls.

I acknowledge and agree to the institution's fee policies and agree to pay any fees disclosed in account disclosures or assessed pursuant to account activity.

I agree to indemnify and hold the institution harmless from liabilities arising from reliance on representations and instructions made hereunder, except to the extent of the institution's gross negligence or willful misconduct.

8. Tax Withholding and Certification

Provide taxpayer identification information and certify tax status for withholding purposes. Applicant certifies under penalty of perjury that the TIN provided is correct and the applicant is not subject to backup withholding unless indicated.

Individual / Sole proprietor

Corporation

Partnership

Other:

9. Privacy, Electronic Delivery & Communications Consent

Applicant acknowledges receipt of privacy and data protection notices provided separately and consents to electronic delivery of account disclosures, statements, and notices where permitted by law. Applicant affirms they will provide current contact information and notify the institution of changes.

I consent to electronic delivery of disclosures, statements, and tax documents where permitted by law.

I consent to receive communications by phone, email, and SMS to the contact information provided above for account administration and risk notifications.

10. Fees, Liability and Governing Law

Fees for services, including account maintenance, transaction fees, and returned item fees, will be assessed in accordance with the institution's fee schedule. The applicant acknowledges that the institution's liability for errors or unauthorized transactions will be governed by contract terms, applicable law, and applicable electronic funds transfer rules. This Form and the applicant's relationship with the institution will be governed by the laws of the jurisdiction specified in the account agreement, without regard to its conflict-of-law provisions.

11. Additional Information / Notes

12. Terms & Conditions — Applicant Acknowledgement

The undersigned represents and warrants that they are authorized to execute this Financial ICCU Form on behalf of the applicant. The undersigned affirms that all statements are true and complete. The applicant agrees to provide documentation as reasonably requested to support the representations contained herein and understands that the institution may suspend or close accounts for material misrepresentations or failure to provide requested information.

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