Plains State Bank

Personal Deposit 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.


Type of Account
       

1st Signer

Name:
Street Address:
City:
Mailing Address:
City:
Home Phone: Work Phone:
Social Security #
Occupation:
Employer:
Birth Date: Birth Place:
KS Drivers License or ID# Mothers Maiden Name:
Account Formerly With:  
 

2ND Signer

       
Name:
Street Address:
City:
Mailing Address:
City:
Home Phone: Work Phone:
Social Security #
Occupation:
Employer:
Birth Date: Birth Place:
KS Drivers License or ID# Mothers Maiden Name:
Account Formerly With:  
 

Ownership

 
 

If Payable on Death, Name and Address of Relation...

Name (First, Middle, Last):
Street Address:
City:
State:
Zip: -
Social Security Number:
Relationship: