Payable on Death (POD)/Trust Account
Beneficiary/POD Payee:
Street:
Beneficiary/POD Payee:
Street:
UTMA/UGMA
Signature:
Date:
TIN CERTIFICATION AND BACKUP WITHHOLDING INFORMATION
City/State/Zip:
Designate Specific Accounts:
Name of Agent: _____________________________________________________________
City/State/Zip:
All Accounts
All Accounts Designate Specific Accounts: ____________________________________________
Physical Address:
Primary Phone:
Name #3: SSN/TIN:
Mailing Address: ID Type:
City/State/Zip: ID Number:
ID Issuing State:
ID Exp. Date:
ID Issuing Date:
Date of Birth:
Listed Unlisted
City/State/Zip:
Joint Owner
Other Authorized Signer (Describe): __________________________________
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Agent
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Security Code:
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Occupation/Title:
Secondary Phone:
E-Mail:
Employer:
ACCOUNT TYPES
Share/Savings:
Mobile Banking:
Overdraft Protection
Indicate transfer priority:
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Share Draft/Checking:
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Share Certificate/Certificate:
Money Market:
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Audio Response:
ATM Card:
1. ___________________________________________________
ACCOUNT DESIGNATIONS
Debit Card:
Other:
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2. ___________________________________________________
4. ___________________________________________________
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ACCOUNT SERVICES
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Bill Payment:
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3. ___________________________________________________
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Internet Banking:
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SSN/TIN:
Date of Birth:
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Update
SSN/TIN:
Date of Birth:
___________________________________________ (as custodian for _______________________________________________________ (minor)
under the Uniform Transfers/Gifts to Minors Act.) Minor's SSN/TIN: __________________________________________________________
Agency
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Under penalties of perjury, I certify that:
(1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued), and
(2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by
the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or
dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
(3) I am a U.S. citizen or other U.S. person. For federal tax purposes, you are considered a U.S. person if you are: an individual
who is a U.S. citizen or U.S. resident alien; a partnership, corporation, company, or association created or organized in the
United States or under the laws of the United States; an estate (other than a foreign estate); or a domestic trust (as defined in
Regulations Section 301.7701-7).
(4) The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification Instructions. Check the box for item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. By checking this box, this serves to strike
out the language related to underreporting. Complete a W-8 BEN if you are not a U.S. person. If a W-8 BEN is completed, your signature
does not serve to certify this section.
JOINT OWNER/AUTHORIZED SIGNER INFORMATION (continued)
DX1004-e
Listed Unlisted
Other:
Other:
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Update
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Exempt payee code (if any) Exemption from FATCA reporting code (if any)
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signature
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