Consumer Deposit 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

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

If applying for a Certificate of Deposit, what term? Specify Other CD Term

Primary Account Holder

First Name Middle Initial Last Name Suffix Social Security Number Birth Date Street Address City State Zip Code Mailing address is different than street address.

Mailing Address City State Zip Code

Form of Photo Identification Issued By ID Number Issue Date Expiration Date Home/Cell Phone Number Work Phone Number E-mail Address Occupation Employer Name Years Employed at Current Employer

Secondary Account Holder

First Name Middle Initial Last Name Suffix Social Security Number Birth Date Street Address City State Zip Code Mailing address is different than street address.

Mailing Address City State Zip Code

Form of Photo Identification Issued By ID Number Issue Date Expiration Date Home/Cell Phone Number Work Phone Number E-mail Address Occupation Employer Name Years Employed at Current Employer

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 Street Address City State Zip Code Relationship to holder

Opening Deposit

Deposit Amount Deposit Type

Additional Services

Check all that are of interest Visa Debit Card Bill Payment Mobile Banking eStatements Installment Loans Overdraft line of credit Mortgage Loan External Transfers Home Equity Line of Credit

Signature Card 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, I will complete my signature card in front of a Notary and send in a deposit

Certification

By submitting this application, I certify that I/we 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 United Republic Bank's web site or delivered to the e-mail address I provide.

Primary Account Holder's Signature Date

Secondary Account Holder's Signature Date

Type the numbers you see above: