National Credit Federation (NCF)

Enrollment Form 2009 Date of enrollment:

Member ID:
MEMBER
Name:

SS#: Date of Birth:

Mailing Address: Residence Address (if different from mailing address):

Previous Address: (if less than 2 years) Home Phone:

Work Phone:
Cell:
E-mail:

Member ID:
SPOUSE
Name:

SS#: Date of Birth:

Previous Address: (if less than 2 years) ←If different from his/her spouse’s previous address

Cell:
E-mail:
PAYMENT Plan Name:
Initial: $ / / Pmt 1: $ due / /
Number Payments:
*We will debit account on same day of the month as listed in Pmt 1 for total number of payments.

Checking Info:
Bank Name and Address:
Account #: Routing #:

Credit Card Info (circle one) Visa MasterCard AmEx Discover

Name on Card: Card #:
Expiration Date: Security Number:
Comments:

Referred by:
Consultant:
Dear Newest Member,

Congratulations on your decision to become a National Credit Federation Member! We are

dedicated to the complete turnaround of your credit profile. You are officially enrolled and we are
eager to get started to work with you on your behalf!

You will be receiving an email with a username and password so that you can access your
account. Please allow 48 hours for processing. You are eligible to take advantage of any of the
member services that meet your needs. Members may call Member Services to get answers to any of
your questions:
1 (877) 720-7587
All correspondence should be mailed to: Member Services
5364 Ehrlich Rd #399
Tampa, FL 33624

Please keep this phone number and address as a reference so that you can refer back to them at any
time.

Enclosed in this document are basic, step by step instructions on getting started and some
forms that we need from you. There are five (5) things that we need from you to get started on your
file. Please mail the following to the above address:

1. NCF Membership Agreement

2. Attorney-Client Agreement/Items to be Appealed/Limited Power of Attorney
3. Copies of Required Identification
4. Most recent copy of your credit reports
5. Membership Payment Authorization

We need the originals of all items that require your signature, but we encourage you to make copies
for your own records.

Again, welcome to our organization! Please read through the step by step instructions on the
next page and if you have any questions please call Member Services at the number listed above. We
are so pleased to be working with you!

Sincerely,

Herschel Bentley
Executive Director
National Credit Federation
 Step-By-Step Instructions
3 easy steps to a brighter Financial Future!

Step 1

Mail in initial documents:

1. NCF Membership Agreement
2. Attorney-Client Agreement/Items to be Appealed/Limited Power of Attorney
3. Copies of Required Identification (see Required Identification page for details)
4. Copies of most recent credit reports
5. Membership Payment Authorization

If you do not have recent copies of your credit report: Go to www.annualcreditreport.com to order
FREE updated copies. Upon receipt of your credit report(s), you are advised to make copies for your
records and make note of the date you forwarded the original to Member Services. If you want to
verify date of delivery we recommend Confirmed Delivery which is less expensive than Certified Mail.

Important: Contact Member Services if you do not receive all three credit bureau reports within 30
days from the date that you requested them or if you have any questions about how to order reports.

Step 2

Receive Response: You should receive a response to the dispute(s) including an updated report within
60 days. It is required by law that the credit reporting bureaus send their correction report(s) directly
to the consumer.

Mail Update to us: Please forward everything the bureaus mail you. (Including any propaganda
regarding credit repair because this dates and verifies that the bureau(s) have received the challenge.
They do not send a 2nd copy to your attorney.)

Include Payment: Make check or Money Order payable to your attorney (multiply $5.00 times the
number of deletions) and enclose with the updated credit reports. The updates-to-positive status
results will be billed by your attorney’s office.

Important: Please contact Member Services if you do not receive all three credit bureau responses to
the disputes within 60 days after completing Step 1.

Step 3

Repeat Step 2 until file is clean!

 Required Identification
It is important that copies of your required ID be clean and legible or the bureaus may choose to not
process disputes. Please mail (1 set) of your ID to Member Services.

Set of ID includes proof of:

1. Your legal name*

2. Date of birth
3. Social security number
4. Current mailing address**

Lists of acceptable ID for each category:

Name & Date of birth:

• Current driver’s license
• State ID card or Passport
• Military ID
• W2 form

To verify Social Security Number:

• Social security card
• Letter from the SS administration
• Medicaid or Medicare card
• Paycheck stub
• W2 form

Address verification:
• Utility bill
• Paycheck stub
• Medicaid or Medicare card
• Stamped post office box receipt

Note: Some documents include proof of more than one ID requirement; for example, a driver’s license
could cover name, DOB and address.

*To verify a name change also provide a copy of documentation: marriage certificate, letter from the
SS administration, adoption, divorce, etc.

** 2 proofs of address required if less than 2 years at place of residence or use of a PO Box as a mailing
address
 Important: Do Not Fax
1. Processing disputation letters cannot precede without all required documents listed on page
3. Note: if identification is not legible we recommend increasing the size by 20 percent.
2. We recommend you keep a record of mail tracking numbers and list the documents you mailed
on that date.
3. Credit Bureaus use delay tactics. Please notify Member Services is you do not receive all
answers to disputes by 60 day deadline.
4. Inquiries are not automatically disputed. Please cross out your authorized inquiries (especially
open accounts) when you request this free service.
5. Re-investigation cycles are slightly longer.
 Membership Agreement
Mail To: NCF – 5364 Ehrlich Rd #399, Tampa, FL 33624

Last_____________________________________________First__________________________________MI___

SSN#______-_____-______ DOB_____/______/______

Mailing Address:_____________________________________________________________________________
City State ZIP

Home Address (if different)_____________________________________________________________________

City State ZIP
Home Phone (_____) ____________________ Cell Phone (_____)____________________

E-mail_____________________________________________________________________________________

Who were you referred by?_____________________________________________________________________

PARTNER INFORMATION

Last______________________________________________First________________________________MI____

SSN#______-_____-______ DOB_____/______/______

Cell Phone (______) ______________________

E-mail______________________________________________________________________________________

Right to Cancellation: MEMBER may cancel this membership agreement without penalty or further
obligation at any time before midnight of the fifth (5th) business day after the date on which you signed the
membership agreement. See the NOTICE OF CANCELLATION form.
Liability: With regard to SERVICES by NCF or its affiliates, NCF shall not be liable to member for any
acts or omissions in the performance of SERVICES except when the acts or omission are due to willful
misconduct or gross negligence. MEMBER shall hold NCF and its affiliates harmless from any obligations,
costs, claims, judgments, attorneys’ fees and attachments arising from or growing out of SERVICES
rendered, except if NCF is adjudged to be guilty of willful misconduct or gross negligence by a court of
competent jurisdiction.
Member Investment Warranty: As long as you have complied with the terms of your membership
agreement we believe you should not have to pay for ineffective service:
If there are no derogatory items removed from your report in the first 3 months of membership, at your
request we will terminate your membership and refund you all membership fees paid.
At the conclusion of your 12 month membership, if there has not been an increase in your credit score we
will refund 100% of your membership fee.
This membership agreement is between National Credit Federation (hereinafter referred to as NCF), whose
principal business address is 5364 Ehrlich Rd #399, Tampa, FL 33624 and the undersigned, (hereinafter referred
to as MEMBER) is for the expressed purpose of enrolling MEMBER into NCF.
Term: The term of the membership shall be for ONE year.
Purpose: The MEMBER desires to become enrolled into the NCF program. NCF agrees to extend to MEMBER
all of the benefits as printed in the NCF Member Benefit Guide (hereinafter referred to as SERVICES).
Responsibilities of Member: Member agrees to send the following items to NCF immediately upon joining NCF:
Signed membership agreement, attorney-client agreement, copies of required identification (see Required
Identification page for details), copies of most recent credit reports, and membership payment authorization. If
member pays by installment, member agrees to pay according to the payment schedule. Once the dispute process

Initials_______ Initials_______
begins, Member agrees to send in copies of all responses from credit bureaus. Member also agrees to respond to
all informational requests from NCF case managers. Members must keep name and address information current.
If Member’s address changes, Member must notify NCF as soon as possible and provide a copy of two bills or
statements indicating Member’s new address. Members may be required to complete additional NCF forms
during the dispute process. Upon receipt of notice of deletion or correction of adverse items on the Member’s
credit report, Member agrees to pay $5.00 for each such deletion or correction (refer to attorney-client agreement
for more detail). Member agrees not to sustain any new credit challenges during the term of the membership,
including, but not limited to newly delinquent accounts, or newly opened accounts, or new account applications.
Our experienced NCF case managers may provide advice on any actions Member should take or refrain from
taking to help improve credit scores during the dispute process. This helps avoid any counterproductive activity
during which time NCF is working to improve the Member’s scores. Member agrees to abide by the terms of this
agreement and the attorney-client agreement.
SERVICES: MEMBER acknowledges that a third party frequently facilitates SERVICES. That being the case, it
may become necessary for the service offering to change from time to time as NCF continually strives to seek out
the SERVICES that best meet the MEMBERS’ needs in accordance with the mission of NCF. Many of the NCF
Member Services are provided at no additional charge. A few have modest fees to help cover costs (or) to
comply with State and Federal Law.
♦Credit Audit Verification and Restoration (ERASE BAD CREDIT) Included in your membership is
representation by a NCF affiliated attorney to challenge the 3 major national credit bureaus and force the removal
of derogatory information from your credit report. As a special member benefit only extended to NCF Members
in good standing, our affiliated attorneys will aggressively represent you with NO upfront fees, NO ongoing
monthly fees, in fact your total legal fees are only $5 per deleted or corrected item per credit report payable,
ONLY AFTER YOU ARE NOTIFIED BY THE CREDIT BUREAUS OF YOUR RESULTS billed as a
“correction fee”.
Free Legal Advice: Membership includes a membership into our National Law Club, a national network of over
25,000 attorneys in all 50 states. Services included at NO CHARGE are unlimited phone consultation, attorney
review of legal documents, necessary calls and letters by your attorney, simple wills for you and your family,
advice on representing yourself in small claims court and help with government programs; plus discounted fee
schedule, contingency fees, and hourly rates for more complex issues.
Free Bankruptcy Advice: Members are encouraged to embrace the legal system and to make consistent use of
our highly qualified attorneys who will help them navigate through life’s unexpected legal matters, such as filing
for bankruptcy. Members receive a one hour free phone consultation and review of any legal documents.
Obtain a Secured Credit Card: As a member you are automatically approved for a secured credit card to
purchase computers and consumer electronics. Of course your positive payment history will be reported monthly
to the national credit bureaus further helping you re-establish your credit.
Free Credit Card Search Service: Conduct an online data base search of all the banks in the US that offer sub-
prime secured, unsecured and partially secured credit cards. We guarantee to have you approved for a minimum
of two (2) new credit lines.
IRS Defense: One of our highly experienced tax law attorneys that have represented numerous consumers against
the IRS will provide advice. Members receive one (1) free hour of telephone consultation. Members receive
discounts if additional assistance is needed.
Credit Reference Service: NCF will provide a written credit reference at anytime for current valid members.
♦NCF has negotiated an exceptional program on behalf of its members. Token fees may apply to cover costs (or)
comply with State and Federal laws.

By signing below members acknowledges and agrees to the agreement terms above:

____________________________ ________________________ ____/ ____/____

Members Signature Members Print Name Date

____________________________ ________________________ ____/ ____/____

Members Signature Members Print Name Date

Herschel Bentley, Executive Director, NCF

 Attorney – Client Fee Agreement
This agreement (“Agreement”) between Daniel Tam, P.A., an Attorney and Counselor at Law (hereinafter referred to as the
“ATTORNEY”) endorsed by National Credit Federation (hereinafter referred to as NCF); the ATTORNEY whose mailing
address is: 5364 Ehrlich Rd #399, Tampa, FL 33624 and the undersigned (hereinafter referred to as “CLIENT”) is for the
limited purpose of seeking credit report verification and/or removal of errors, misrepresentations or unverifiable information,
that the CLIENT will advise the ATTORNEY regarding items that have been improperly reported on his/her credit report(s).
We do not cover any new items that may appear in CLIENT’s credit files after the initial credit reports are submitted to NCF.
CLIENT agrees to allow the ATTORNEY to represent CLIENT’s interests in this matter. The ATTORNEY agrees to act
diligently in the pursuit of this matter, and will carry out this Agreement within all Federal and State laws.

Term: The term of this Agreement shall be the same as the term of the CLIENT’s membership with NCF. Many CLIENTS
complete the process within 4-6 months. Some may require ATTORNEY’s service for the entire year term of the CLIENT’s
NCF Membership Agreement. The most important variables are the complexity of your case, the CLIENT’s timely
forwarding of credit reports, the responsiveness of the credit bureaus and the CLIENT’s creditors.

Customer Service: CLIENT acknowledges that customer service may be handled by NCF support staff. CLIENT is
requested not to contact the ATTORNEY by phone. Attorney telephone consultations are not included in this agreement.
CLIENT may request to schedule a telephone appointment with ATTORNEY. The fee for the telephone consultation is
$100.00 for up to 30 minutes and must be paid in advance of the consultation.

Client Services and Responsibilities: The FACT Act requires the credit bureaus to provide a free credit report per 12
month period (if requested by the consumer). The CLIENT agrees to promptly request all three credit reports and if
necessary to pay directly to the credit bureaus any fee that may be required to obtain their credit report from the bureaus.
CLIENT agrees to forward promptly any and all correspondence and credit reports received from credit bureaus. The
ATTORNEY will then perform a bi-monthly Credit Verification Audit. The Credit Verification Audit includes the evaluation
of all credit bureau report(s), creditor letter(s), etc. and all correspondence associated with the verification process. CLIENT
authorizes the ATTORNEY to prepare all necessary correspondence and negotiate the clarification and removal of certain
unverifiable derogatory information that may be contained in the CLIENT’S credit reports. Upon request, CLIENT agrees to
provide honest and accurate information related to the items in dispute. Failure to do so may void this agreement. CLIENT
acknowledges that no solicitation has been made by Daniel Tam, P.A. or any of its employees to perform credit repair
services. The CLIENT agrees to notify the ATTORNEY by contacting NCF Member Services if their updated credit report(s)
or correspondence(s) are not received within 60 days from the last version mailed to the NCF Member Services department.
The ATTORNEY will notify NCF Member Services when the case is completed to halt the process.

Confidentiality: CLIENT understands that due to the nature of the service provided by the ATTORNEY that his/her credit
file and its contents may be viewed by employees of the ATTORNEY and/or NCF Member services that will assist in this
matter. All employees such as paralegals, research assistants, and administrative personnel have been alerted to the sensitivity
of these documents and take all reasonable measures to insure that this information will be handled in a responsible manner.
The ATTORNEY will keep confidential all information associated with credit files and the services being provided to
CLIENT.

Fees: In consideration for ATTORNEY’s service, CLIENT agrees to pay ATTORNEY at rates, and under the conditions set
forth herein. ATTORNEY’s right to receive fees shall accrue only after ATTORNEY has achieved the removal of one or
more items from any of CLIENT’s credit reports. The fees charged by ATTORNEY, and which CLIENT promises to pay,
shall be limited to $5.00 per corrected or improved item per credit report (the “Correction Fee”). The parties mutually agree
that a corrected item is defined as a derogatory item listed on the CLIENT’s credit report that is DELETED, IMPROVED or
AMENDED to a favorable status. There is no charge for inquiries removed from CLIENT’s credit report(s). Correction Fees
will be considered earned immediately after CLIENT receives notification from a credit bureau that item(s) previously listed
as derogatory are improved to a favorable status or deleted, which shall give rise to the CLIENT’s obligation to pay the
Correction Fee(s). The failure of the CLIENT to pay any Correction Fee to ATTORNEY as it becomes due shall be grounds
for immediate termination of this Agreement and of the CLIENT’s NCF membership agreement, without further notice to the
CLIENT.

No Guarantee: Due to the nature of any legal proceeding it is impossible and unethical for ATTORNEY to offer any
absolute assurances as to the outcome of the ATTORNEY’s efforts on behalf of the CLIENT. For this reason no guarantee is
suggested or implied by this Agreement. FOR FURTHER INFORMATION SEE NCF MEMBER WARRANTY.

Initials_______ Initials_______
Cancellation: CLIENT may cancel this Agreement at any time by sending to ATTORNEY (c/o NCF Member Services) a
written notice of cancellation. However, the ATTORNEY is entitled to receive all Correction Fees earned by ATTORNEY
prior to or on the date of termination of the Agreement. NCF MEMBER acknowledges that cancellation of this Agreement
prior to termination of the CLIENT’s NCF Membership Agreement releases the ATTORNEY from any obligations
expressed in this agreement.

X_________________________ ____/______/_______ #__ __ __ __ -__ __ __ __ -__ __ CC

CLIENT Signature Date ID #

X_________________________ ____/______/______ #__ __ __ __-__ __ __ __-__ __ CC

CLIENT’s Partner Signature (If applicable) Date ID #

__________________________ ____/______/_______
Daniel Tam Date
Attorney at Law

Items to be Appealed
If there are negative items on my credit report I know to be accurate and verifiable, and do not want challenged or removed
from my credit report, I will attach a note to my credit report before forwarding it for processing. I will complete on a timely
basis and return to NCF Member Services any request for supporting information indicating which credit references on my
credit report that I would like challenged or verified.

X_________________________ ____/_____/____ X ________________________ ____/____/____

Client Signature Date Partner Signature (If applicable) Date

Limited Power of Attorney

I, the undersigned, hereby engage the services of Daniel Tam, P.A. and hereby give
Power of Attorney to said firm (including without limitation, attorney Daniel Tam) for
the purpose of requesting verification and disputing any information in regards to my
credit report(s), and to perform any lawful act necessary to conduct such an investigation
of and seek removal of any inaccurate or unverifiable item listed on my credit report(s). I
understand that I may revoke this Limited Power of Attorney agreement at any time by
sending notice in writing to: 5364 Ehrlich Rd #399, Tampa, FL 33624

I the undersigned also acknowledge receipt of my Consumer Credit File Rights

Under State and Federal Law and my Right to Cancel Agreement Form .

X_________________________ ____/____/____ X________________________ ____/____/____

Client Signature Date Partner Signature (If applicable) Date

___________________________ ____/____/____ _________________________ ____/____/____

Client Printed Name Date of Birth Partner Printed Name Date of Birth

Social Security No. __ __ __ - __ __ - __ __ __ __ Social Security No. __ __ __ - __ __ - __ __ __ __

Please Print Clearly in Black Ink

National Credit Federation

Membership Payment Authorization by Credit Card

Name on Card: _________________________________________________

Billing Address: _________________________________________________

___________________________________ _____ ________

City State ZIP

(circle one) Visa Master Card American Express Discover

Account Number_________________________________________________________

Expiration Date_________________________________________________________

CSC or CVC (the last 3 digits on the back of your credit card)________________

I hereby authorize recurring charges from my credit card listed above according to the
following schedule:

The initial fee of $_______ is to be debited on ___/___/______ (MM/DD/YYYY).

The monthly payments of $________ are to be debited starting on

___/___/______ (MM/DD/YYYY) and on the same day of each month following

for a total of _______ months.

Signature ________________________________ Date ____ / ____ / ____

By my signature above, I acknowledge I have read, understand, and agree to the terms and
conditions of membership enrollment for one year.

I hereby authorize the withdrawal of funds from my credit card listed above for the
payment of Correction Fees pursuant to the terms and during the term of the member
agreement.

Signature ________________________________ Date ____ / ____ / ____

By my signature above, I acknowledge I have read, understand, and agree to the terms and
conditions of membership enrollment for one year.

Member Services
5364 Ehrlich Rd, Tampa, FL 33624 Fax Number 813-926-2728
Please Print Clearly in Black Ink

National Credit Federation

Membership Payment Authorization by Check

Name on Account: _________________________________________________

Address on check: _________________________________________________

___________________________________ _____ ________
City State ZIP

Bank Name: ______________________________________________________

Bank Address: _____________________________________ _____ ________
City State ZIP

Routing __ __ __ __ __ __ __ __ __ Acct. __ __ __ __ __ __ __ __ __ __ __ __ __ __

I hereby authorize auto-withdrawal(s) from my Checking account according to the

following schedule:

The initial fee of $_______ is to be drafted on ___/___/______ (MM/DD/YYYY).

The monthly payments of $________ are to be drafted starting on

___/___/______ (MM/DD/YYYY) and on the same day of each month following

for a total of _______ months.

Signature ________________________________ Date ____ / ____ / ____

By my signature above, I acknowledge I have read, understand, and agree to the terms and
conditions of membership enrollment for one year.

I hereby authorize the withdrawal of funds from my Checking account listed above for
payment of Correction Fees pursuant to the terms and during the term of the member
agreement.

Signature ________________________________ Date ____ / ____ / ____

By my signature above, I acknowledge I have read, understand, and agree to the terms and
conditions of membership enrollment for one year.

Attach Voided Check Here

Member Services
5364 Ehrlich Rd, Tampa, FL 33624 Fax Number 813-926-2728
 Right to Cancel Agreement Form
You may cancel this contract without any penalty or obligation, at any time before midnight of the 5th business day
which begins after the date the contract is signed by you. Additionally, you may cancel this agreement at any time
provided you acknowledge that by prematurely canceling your one-year agreement you release NCF from any obligation
related to the warranties expressed in the contract including any refund of monies already paid to NCF.

To cancel the contract, mail or deliver a signed copy of this cancellation notice, or any other written notice to Member
Services, 5364 Ehrlich Rd #399, Tampa, FL, 33624

I hereby cancel my contract with the National Credit Federation.

_____________________________________ ___/_____/____
MEMBERS Signature Date

_____________________________________ ___/_____/____
MEMBERS Partner Signature Date

Member Copy

Right to Cancel Agreement Form

You may cancel this contract without any penalty or obligation, at any time before midnight of the 5th business day
which begins after the date the contract is signed by you. Additionally, you may cancel this agreement at any time
provided you acknowledge that by prematurely canceling your one-year agreement you release NCF from any obligation
related to the warranties expressed in the contract including any refund of monies already paid to NCF.

To cancel the contract, mail or deliver a signed copy of this cancellation notice, or any other written notice to Member
Services, 5364 Ehrlich Rd #399, Tampa, FL, 33624

I hereby cancel my contract with the National Credit Federation.

_____________________________________ ___/_____/____
MEMBERS Signature Date

_____________________________________ ___/_____/____
MEMBERS Partner Signature Date

NCF Copy
 Consumer Credit File Rights Under State and Federal Law
• The Federal Trade Commission regulates credit bureau and credit repair organizations.
• You have the right to dispute inaccurate information in your credit report by contacting the credit bureau
directly. However, neither you nor any “credit repair” company or credit repair organization has the right to
have accurate, current, and verifiable information removed from your report. The credit bureau must
remove accurate, negative, information from your credit report only if it is over 7 years old. Bankruptcy
information can be reported for 10 years.
• You have a right to obtain a copy of your report from a credit bureau. You may be charged a reasonable fee.
There is no fee, however, if you have been turned down for credit, employment, insurance, or a rental
dwelling because of information in your credit report within the preceding 60 days. The credit bureau must
provide someone to help you interpret the information in your credit file. You are entitled to receive a free
copy of your credit report if you are unemployed and intend to apply for employment in the next 60 days, if
you are a recipient of public welfare assistance, or if you have reason to believe that there is inaccurate
information in your credit report due to fraud.
• You have a right to sue a credit repair organization that violates the Credit Repair Organization Act. This
law prohibits deceptive practices by credit repair organizations.
• You have the right to cancel your contract with any credit repair organization for any reason within 3
business days from the date you sign it.
• Credit bureaus are required to follow reasonable procedures to ensure that the information they report is
accurate. However, mistakes may occur. You may on your own, notify a credit bureau in writing that you
dispute the accuracy of information in your credit file. The credit bureau must then reinvestigate and modify
or remove inaccurate or incomplete information. The credit bureau may not charge any fee for this service.
Any pertinent information and copies of all documents you have concerning an error should be given to the
credit bureau.
• If credit bureau’s reinvestigation does not resolve the dispute to your satisfaction, you may send a brief
statement to the credit bureau, to be kept in your file, explaining why you think the record is inaccurate. The
credit bureau must include a summary about disputed information with any report it issues about you.

For more information contact: The Public Reference Branch, Federal Trade Commission, Washington, D.C. 20580

I hereby acknowledge receipt of the above statement

_____________________________________ ___/_____/____
MEMBERS Signature Date

_____________________________________ ___/_____/____
MEMBERSPartner Signature Date
 Authorization To Release Information
To Whom It May Concern:
I/We authorize you to provide to National Credit Federation, any of its affiliates or
agents, a standard factual data credit report and all information and documentation that
they request. This request is made in accordance with section 604(a)(3)(F) of the Fair
Credit Reporting Act.

Any reproduction of this credit report authorization and release made by reliable means
(for example, photocopy or facsimile) is considered an original.

Member Signature:__________________________________________________
Member Name: _____________________________________________________
SSN: ______-____-________
Date:____________________

Co-Member Signature (if applicable):____________________________________

Co-Member Name (if applicable):_______________________________________
SSN: ______-____-________
Date:____________________