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 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 right to survivorship) 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

Opening Deposit

Deposit Amount Deposit Type

Account Preferences

Visa Check Card ATM Card Telephone Banking Would you like us to place a Check Order for you? Would you like an application for Overdraft Protection? Bill Payment I would like to come in and sign my Signature Card and make my deposit.
We will contact you upon account approval to schedule a time that is convenient. I would like for my Welcome Kit to be mailed to me and I will complete my signature card and send in a deposit.

Endorsement

As a condition of acceptance of my deposit application, I authorize you to obtain a copy of my current credit report and subsequent reports for the purpose of an update, renewal or extension of credit. 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 am subject to backup withholding. I am not a United States citizen or resident. 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 Fiserv web site or delivered to the e-mail address I provide, including information required by various laws and regulations. I authorize Fiserv to access my credit bureau information, check my employment, and report to credit reporting agencies Fiserv's experience with me.

Primary Account Holder's Signature Date

Joint Account Holder's Signature Date