Certificate of Deposit Account Application

Important Information About Procedures For Opening A New Account & The Patriot Act

To help the government fight the funding of terrorism and money laundering activities, Federal law requires all 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 you 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.

Account Information

Certificate of Deposit Type Personal Non-Personal

Account Duration

Are you applying for an individual or joint account? Individual Joint

Primary Account Holder Information

First Name Middle Initial Last Name Suffix Social Security Number Birth Date Mother's Maiden Name Driver's License Number State Issued Date of Expiration Street Address City State Zip Code Mailing address is different than street address.

Mailing Address City State Zip Code

Home Phone Number Work Phone Number E-mail Address Please do NOT email me important news and updates. Occupation Employer Name

Joint Account Holder Information

Mailing Address City State Zip Code

Home Phone Number Work Phone Number E-mail Address Please do NOT email me important news and updates. Occupation Employer Name

Ownership

Ownership type Single Owner (individual) Joint (with no right to survivorship) Payable on Death

Beneficiary Information

First Name Middle Initial Last Name Suffix Social Security Number Street Address City State Zip Code Relationship to holder

Business Information

Business Name Tax ID Number Business Phone Number Business Fax Number

Business Type Sole Proprietor Corporation Partnership LLC Non-Profit Other

Business Type Street Address City State Zip Code Mailing address is different than street address.

Mailing Address City State Zip Code

Number of Required Signatures

Business Officer Information

Officer

Officer Title First Name Last Name Social Security Number Birth Date Mother's Maiden Name Driver's License Number State Issued Date of Expiration Home Address City State Zip Code Home Phone Number Work Phone Number E-mail Address Please do NOT email me important news and updates. Occupation Employer Name

Opening Deposit

Deposit Amount Deposit Type

Endorsement

I am not subject to backup withholding, because I am exempt from backup withholding, or because I have not been notified by the IRS that I am subject to backup withholding as a result of failure to report all interest or dividends, or because the IRS has notified me that I am no longer subject to backup withholding. I certify under penalties of perjury that the statements contained in this section are correct.

By submitting this application, I certify that I/we gave truthfully and fully provided the information required and that I am at least 18 years of age and live in the US. I certify that I have read and agreed to all the Terms & Conditions, Disclosures, and Privacy Policy. I agree that I may receive electronic communications posted on the First Missouri State Bank web site or delivered to the e-mail address I provide, including information required by various laws and regulations. I authorize First Missouri State Bank to access my credit bureau information, check my employment, and report to credit reporting agencies First Missouri State Bank's experience with me.

Primary Account Holder's Signature Date

Joint Account Holder's Signature Date