Checking and Savings Account Application

Important Information About Procedures For Opening A New Account

(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.

General

Account Type

Ownership

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

If payable on death, enter beneficiary information.

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

Primary Account Holder

First Name Middle Initial Last Name Suffix Social Security Number Birth Date 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

Opening Deposit

Deposit Amount Deposit Type

Services Needed

Check all that apply Online Banking Remote Deposit Capture Mobile Deposit Capture Debit Card Bill Pay Would you like us to place a Check Order for you? Are you interested in opening any other consumer account with us?

The purpose of this questionnaire is to begin the application process. All applications are subject to approval. We will contact you once the application has been reviewed.

Endorsement

As a condition of acceptance of my deposit application, I authorize you to obtain a copy of my ChexSystems report to process my new account request. 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.