ReliaCard Form ReliaCard First Name * Last Name * Address * City * State * SelectAKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip Code * Phone Number * Social Security Number * Date of Birth * Email Address * Important Information About Procedures For Opening A New Account To help the government fight the funding of terrorism and money laundering activities, Federal law requires al financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: when you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents. I hereby authorize my government agency to initiate credit entries (deposits) and to initiate, if necessary, debit entries and adjustments for any credit entries in error to my ReliaCard. This authorization will remain in effect until cancelled by me with written notification to my government agency. New Enrollees Only: Please complete this form only if you are enrolling in the program for the first time. If you are already enrolled, do not submit a new enrollment form. If your card has been lost, stolen, or damaged, please contact U.S. Bank ReliaCard Customer Service at 855-282-6161 or visit U.S. Bank ReliaCard website for assistance at https://www.usbankreliacard.com. Signature * signature keyboard Clear Date Captcha SUBMIT * Required field If you are human, leave this field blank.
